Accidents and injuries pose significant threats to individuals across all age groups. Understanding and addressing the underlying risks is paramount in healthcare. For young men, accidents and injuries are the primary causes of mortality, while for infants, suffocation is the most prevalent cause of death. Toddlers are particularly vulnerable to drowning. Beyond these, unintentional injuries stem from various sources including motor vehicle accidents, poisoning, drug overdoses, burns, and falls. In the context of nursing, recognizing and mitigating these risks through effective diagnosis and intervention is crucial for patient safety. This article delves into the critical role of NANDA safety nursing diagnoses in creating safer healthcare environments and improving patient outcomes.
Several factors elevate a patient’s susceptibility to injury, broadly categorized into individual and environmental risks.
Individual Risk Factors:
- Neuromuscular Impairments: Conditions affecting muscle strength, gait, and balance significantly increase the risk of falls and other injuries.
- Age Extremes: Both very young and very old individuals are more vulnerable due to physiological and developmental factors.
- Perceptual Disturbances: Impaired sensory perception can hinder awareness of hazards and increase accident risk.
- Chronic Debilitating Illnesses: Weakened physical state and compromised immunity associated with chronic illnesses increase vulnerability to injury.
- Nonadherence with Safety Protocols: Failure to follow safety guidelines, whether intentional or unintentional, directly elevates risk.
- Recent Physical Trauma: Post-trauma recovery often involves physical limitations and pain, increasing vulnerability.
- Low Socioeconomic Status: Limited access to resources and safe environments can contribute to higher injury rates.
- Substance Use: Smoking, alcohol, and drug abuse impair judgment and coordination, increasing accident risk.
- Lifestyle Choices: Certain lifestyle choices can place individuals in more hazardous situations.
- Language Barriers: Communication difficulties can impede understanding of safety instructions and warnings.
- Developmental Barriers: Cognitive or physical developmental delays can limit safety awareness and self-protection abilities.
- Impaired Senses: Vision or hearing impairments reduce environmental awareness and increase accident potential.
- Complex Therapeutic Regimens: Managing multiple medications or treatments can lead to confusion and errors, indirectly increasing injury risk.
- Psychological Illnesses or Emotional Grief: Mental health conditions and emotional distress can impair judgment and increase risk-taking behaviors.
- Lack of Assistive Support or Supervision: Insufficient support systems can leave vulnerable individuals without necessary protection.
Environmental Risk Factors:
- Unsafe Weather-Related Conditions: Extreme weather events like storms, ice, or heatwaves can create hazardous environments.
- Cluttered Environments: Disorganized spaces increase the risk of trips, falls, and accidents.
- Insufficient Automobile Restraints: Lack of or improper use of seatbelts and car seats significantly increases injury severity in accidents.
- Insufficient Lighting: Poorly lit areas increase the risk of falls and collisions.
- Lack of Resources or Equipment: Inadequate safety equipment in workplaces or homes elevates injury risks.
- Occupational Hazards: Certain occupations inherently involve higher risks of injury due to machinery, chemicals, or physical demands.
Diagnostic procedures like laboratory tests and imaging are crucial in assessing the extent of injuries, such as fractures or internal bleeding. Proactive safety measures, like barium swallow studies to prevent aspiration during swallowing assessments, are also vital.
The Nursing Process and Patient Safety
Patient safety is a cornerstone of nursing care, taking precedence immediately after ensuring a patient’s airway, breathing, and circulation are stable. Inpatient settings inherently present heightened injury risks due to factors such as compromised immune systems, unfamiliar surroundings, invasive procedures and equipment, potent medications, and potential alterations in mental status. Consequently, nursing care plans frequently incorporate safety elements aimed at preventing injuries and harm both during hospitalization and after discharge.
Utilizing Nursing Care Plans for Safety
Once nurses identify NANDA safety nursing diagnoses relevant to a patient’s condition, nursing care plans become essential tools for prioritizing assessments and interventions. These plans guide both short-term and long-term care goals focused on patient safety. The following sections provide examples of nursing care plans centered around patient safety, specifically addressing common NANDA safety nursing diagnoses.
Risk for Aspiration
Aspiration, the inhalation of substances into the airway, poses a serious threat to vulnerable patients. This is a crucial Nanda Safety Nursing Diagnosis to consider.
Nursing Diagnosis: Risk for Aspiration
Related Factors:
- Reduced level of consciousness
- Depressed cough or gag reflexes
- Impaired swallowing
- Impaired protective reflexes
- Oral or facial surgery or trauma
- Stroke or paralysis
- Presence of a tracheostomy
- Tube feedings
As evidenced by:
Risk diagnoses are not defined by existing signs and symptoms, as the problem is yet to occur. The focus of nursing interventions is purely preventative.
Expected Outcomes:
- The patient will maintain a clear airway.
- The patient will not experience aspiration episodes, indicated by:
- Absence of coughing after swallowing
- Absence of hoarseness
- No food pocketing in the mouth
- No changes in respiratory status or abnormal lung sounds
- No alterations in level of consciousness
Assessment:
- Confirm enteral tube feeding placement. Verification methods include X-ray, pH testing, or bedside auscultation. Patients with intubation, decreased consciousness, or neurological impairment are at a heightened aspiration risk.
- Monitor gag reflex. Assess the gag and swallow reflex at the bedside before oral intake. Concerns warrant further evaluation via a swallow study.
Interventions:
- Elevate the head of the bed to 30-45 degrees during tube feedings. This position utilizes gravity to prevent reflux. Maintain this elevation for one hour post-feeding.
- Monitor gastric residual volumes before or between bolus feedings. High residuals may indicate poor digestion or esophageal sphincter incompetence, increasing aspiration risk. Hold feedings and consult the physician for guidance.
- Explore alternative medication formulations. Patients with swallowing difficulties, particularly children, may require crushed pills, liquid formulations, or disintegrating tablets.
- Suction oral and throat secretions. Suctioning clears the airway. Tracheostomy patients often require frequent suctioning to manage mucus.
- Educate the family on aspiration prevention. Patients requiring feeding need close supervision during meals. Avoid rushing, offer small bites, encourage thorough chewing, and consider easily swallowed foods.
Risk for Falls
Falls are a major safety concern in healthcare, and “Risk for Falls” is a frequently used NANDA safety nursing diagnosis.
Nursing Diagnosis: Risk for Falls
Related Factors:
- Altered glucose levels
- Decreased lower extremity strength and balance
- Unsafe or cluttered environment
- Use of assistive devices (improperly fitted or used)
- Acute illnesses
- Chronic conditions affecting mobility
- Older age
- Environmental hazards
- Disorientation
As evidenced by:
As a risk diagnosis, there are no existing signs or symptoms. Interventions aim to prevent the occurrence of falls.
Expected Outcomes:
- The patient will not experience any falls.
- The patient will demonstrate fall prevention measures.
Assessment:
- Assess patient-specific risk factors for falls. Individuals aged 65 and older or those with predisposing conditions are at higher risk.
- Evaluate assistive device use and safety. Assess gait and equipment needs. Observe correct equipment usage.
Interventions:
- Review and monitor medication use. Sedatives and narcotics can cause drowsiness and increase fall risk, especially in new users. Educate patients about potential side effects of new medications affecting balance or cognition prior to discharge and continuously monitor their effects.
- Ensure a hazard-free environment. Unfamiliar settings increase fall risk. IV lines, pumps, oxygen tubing, and sequential compression devices can become tripping hazards.
- Collaborate with Physical Therapy (PT) and Occupational Therapy (OT). Patients may need exercises to improve strength, coordination, and balance. PT/OT can recommend assistive equipment to enhance safety.
- Maintain a low bed position with bed alarm activation. Patients identified as high fall risks should always have their bed in the lowest position with the bed alarm on when staff are not present at the bedside.
Risk for Injury
“Risk for Injury” is a broad NANDA safety nursing diagnosis encompassing vulnerability to harm from various internal and external factors.
Nursing Diagnosis: Risk for Injury
Related Factors:
- Altered cerebral function
- Impaired mobility
- Loss of limbs
- Impaired vision
- Hearing impairment
- Malnutrition
- Psychosis
- Medication side effects
- Exposure to chemicals
- Immunosuppression
As evidenced by:
Risk for Injury, being a risk diagnosis, is not evidenced by current signs or symptoms. Nursing actions are focused on preventing injury.
Expected Outcomes:
- The patient will identify factors increasing their risk of injury.
- The patient will implement safety measures to prevent injury.
- The patient will remain free from injury.
Assessment:
- Assess physical and emotional factors impacting safety. Disturbed thought processes, grief, sleep deprivation, recent trauma, and major health changes can impair judgment and increase injury risk.
- Consider socioeconomic factors. Lack of stable housing, transportation, or access to essential resources can increase injury risk due to inadequate self-care and limited medical support.
- Assess for potential abuse. Nurses are mandatory reporters of suspected abuse. Assess for unexplained bruises in various healing stages, frequent fractures, and inquire about emotional or verbal abuse.
Interventions:
- Refer to community resources as needed. Ensure vulnerable patients receive appropriate care to prevent injuries. This may include in-home care or daycare services for children, adults with developmental delays, or older adults with dementia.
- Administer medications using the “5 Rights” of medication administration. Double-checking the right patient, medication, dose, route, and time minimizes medication errors. Utilize medication scanners if available and avoid bypassing safety checks.
- Educate patients and families on basic safety measures. Injury prevention requires family awareness and adherence to safety practices, such as proper use of medical equipment, seatbelt use, and secure storage of medications and cleaning products.
- Instruct families on basic first-aid strategies. Despite preventative measures, accidents can occur. First-aid knowledge enables prompt intervention and prevents complications.
References
- Appeadu MK, Bordoni B. Falls and Fall Prevention In The Elderly. [Updated 2022 Feb 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560761/
- Bazakis AM, Kong EL, Deibel JP. Fatal Accidents. [Updated 2022 Sep 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482328/
- 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.
