Injuries can occur in any healthcare setting and can have serious consequences for patients. In order to prevent injuries, nurses must be able to identify patients at risk and implement interventions to reduce that risk. The NANDA nursing diagnosis of “Risk of Injury” is used to identify patients who are at risk for injury and to guide nursing interventions to prevent it.
NANDA Nursing Diagnosis Definition
According to NANDA International, the official definition of “Risk of Injury” is: “Potential for harm to the body from an external source, as evidenced by a vulnerable body part, environmental hazard, or other risk factor.”
Defining Characteristics
- Vulnerable body parts such as skin breakdown, impaired mobility, or decreased sensation
- Environmental hazards such as wet floors, poor lighting, or lack of handrails
- Other risk factors such as confusion, disorientation, or impaired cognition
- History of previous injuries or falls
- Changes in level of consciousness or alertness
Related Factors
- Impaired mobility
- Impaired sensation
- Impaired cognition
- Age-related changes
- Medications that cause drowsiness or confusion
- Environmental hazards
- Lack of assistive devices
- Lack of knowledge about safety measures
Risk Population
Individuals who are at a higher risk for injury include:
- Elderly adults
- Individuals with chronic medical conditions such as dementia or Parkinson’s disease
- Individuals with impaired mobility or sensation
- Individuals taking sedatives or opioids
- Individuals with high levels of stress or anxiety
- Individuals who have a history of falls or previous injuries
Associated Problems
- Falls
- Trauma
- Infection
- Increased length of hospital stay
- Decreased functional ability
- Decreased quality of life
- Increased healthcare costs
Suggestions for Use
- Assess the patient’s risk for injury by evaluating their physical and cognitive status, medications, and environmental factors.
- Implement fall prevention measures such as bed alarms and assistive devices.
- Implement safety measures such as proper lighting and handrails in the patient’s environment.
- Educate the patient and their family about safety measures and how to reduce the risk of injury.
- Monitor the patient’s physical and cognitive status, and adjust interventions as necessary.
- Regularly assess the patient’s medications and their potential impact on the risk of injury.
- Encourage and assist the patient with mobility and physical activity to improve functional ability and reduce the risk of falls.
Suggested Alternative NANDA Diagnoses
- Impaired Physical Mobility
- Impaired Sensory Perception
- Impaired Tissue Integrity
- Impaired Verbal Communication
- Risk for impaired skin integrity
Usage Tips
- This diagnosis should be used in conjunction with other diagnoses that may be contributing to the patient’s risk of injury, such as impaired mobility or impaired cognition.
- It is important to monitor the patient’s response to interventions and adjust as necessary.
- It is also important to consider the patient’s overall health history and any previous injuries or falls they may have experienced.
- In cases where the patient is experiencing a high risk of injury, referral to a physical therapist or occupational therapist may be necessary.
NOC Results
- Injury prevention: This outcome measures the effectiveness of interventions in reducing the patient’s risk of injury.
- Physical mobility: This outcome measures the patient’s ability to move about safely, which can be affected by a risk of injury.
- Sensory perception: This outcome measures the patient’s ability to perceive and respond to their environment, which can be affected by a risk of injury.
- Tissue integrity: This outcome measures the patient’s skin and tissue integrity, which can be affected by a risk of injury.
- Verbal communication: This outcome measures the patient’s ability to communicate effectively, which can be affected by a risk of injury.
NIC Interventions
- Fall Prevention: This intervention involves implementing measures to prevent falls, such as bed alarms and assistive devices.
- Safety Measures: This intervention involves implementing safety measures in the patient’s environment, such as proper lighting and handrails.
- Education: This intervention involves educating the patient and their family about safety measures and how to reduce the risk of injury.
- Assistive Devices: This intervention involves providing the patient with assistive devices, such as walkers or canes, to improve mobility and reduce the risk of falls.
- Medication Management: This intervention involves monitoring and adjusting the patient’s medications to minimize their negative impact on the risk of injury.
- Physical Therapy: This intervention involves referring the patient to a physical therapist to improve their mobility and reduce the risk of injury.
- Environmental Assessment: This intervention involves evaluating the patient’s environment and making necessary changes to reduce the risk of injury.
- Patient Monitoring: This intervention involves regularly monitoring the patient’s physical and cognitive status and adjusting interventions as necessary.
Conclusion
The NANDA nursing diagnosis of “Risk of Injury” is crucial for identifying patients who are at risk for injury and implementing interventions to prevent it. By understanding the diagnosis and related factors, nurses can take appropriate action to promote safety and reduce the risk of injury in at-risk patients.