Physical trauma is a serious concern in any healthcare setting, as it can have severe consequences for patients. In order to prevent physical trauma, nurses must be able to identify patients at risk and implement interventions to reduce that risk. The NANDA nursing diagnosis of “Risk of Physical Trauma” is used to identify patients who are at risk for physical trauma and to guide nursing interventions to prevent it.
NANDA Nursing Diagnosis Definition
According to NANDA International, the official definition of “Risk of Physical Trauma” is: “The potential for harm or injury related to the patient’s physical environment, as evidenced by factors such as history of falls, presence of hazardous equipment or environment, or alterations in level of consciousness.”
Defining Characteristics (Subjectives and Objectives)
- History of falls or other physical trauma
- Presence of hazardous equipment or environment
- Alterations in level of consciousness such as confusion or disorientation
- Impairments in mobility or physical function
- Symptoms such as bruises, cuts, or fractures
- Age-related changes in physical function or mobility
- Chronic illnesses or conditions that affect mobility or physical function
- Medications that can cause drowsiness or confusion
- Lack of knowledge or understanding about potential hazards in the environment
- Poor lighting or inadequate lighting in the environment
- Environmental hazards such as wet floors or uneven surfaces
Individuals who are at a higher risk for physical trauma include:
- Elderly individuals
- Individuals with chronic illnesses or conditions that affect mobility or physical function
- Individuals taking medications that can cause drowsiness or confusion
- Individuals with cognitive or physical impairments
- Individuals who are visually or hearing impaired
- Individuals living in environments with poor lighting or inadequate lighting
- Fractures or dislocations
- Head injuries
- Soft tissue injuries such as bruises or lacerations
- Increased risk of infection
- Decreased mobility or physical function
- Prolonged recovery time
- Emotional distress such as anxiety or depression
- Increased healthcare costs
Suggestions for Use
To prevent physical trauma, nurses should take the following steps:
- Assess the patient’s risk for physical trauma by taking a thorough history and identifying any potential hazards in the environment.
- Implement safety measures to limit the patient’s exposure to hazards, such as providing appropriate equipment or modifying the environment.
- Educate the patient and their family about potential hazards and how to prevent physical trauma.
- Monitor the patient’s physical condition and report any changes to the healthcare provider immediately.
- Administer appropriate treatments and interventions, such as wound care or physical therapy.
- Regularly assess and adjust the patient’s medications to minimize the risk of side effects that can contribute to physical trauma.
Suggested Alternative NANDA Diagnoses
- Impaired Mobility
- Impaired Physical Mobility
- Impaired Tissue Integrity
- Risk for Falls
- Risk for Injury
- This diagnosis should be used in conjunction with other diagnoses that may be contributing to the patient’s risk of physical trauma, such as Impaired Mobility or Impaired Tissue Integrity.
- 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 experiences with physical trauma.
- Tissue Integrity: This outcome measures the effectiveness of interventions in maintaining the integrity of the patient’s skin and mucous membranes, which can be damaged by physical trauma.
- Mobility: This outcome measures the patient’s ability to move, which can be impaired by physical trauma.
- Safety: This outcome measures the patient’s overall level of safety, including their risk of physical trauma.
- Comfort: This outcome measures the patient’s level of comfort and the effectiveness of interventions to reduce discomfort related to physical trauma.
- Health Perception: This outcome measures the patient’s understanding of their own health status and risk factors, including their risk of physical trauma.
- Fall Prevention: This intervention involves implementing strategies to reduce the patient’s risk of falls, such as providing assistive devices or modifying the environment to eliminate hazards.
- Safety Measures: This intervention involves identifying and addressing any potential hazards in the patient’s environment and implementing safety measures to minimize the risk of physical trauma.
- Patient Education: This intervention involves educating the patient and their family about the risk of physical trauma and how to prevent it, including proper use of assistive devices, safe mobility techniques, and fall prevention strategies.
- Patient Monitoring: This intervention involves regularly monitoring the patient’s physical and cognitive status, vital signs, and symptoms, and adjusting interventions as necessary to minimize the risk of physical trauma.
- Wound Care: This intervention involves providing appropriate care for any injuries sustained as a result of physical trauma, including cleansing and dressing wounds, administering medication, and providing pain management.
The NANDA nursing diagnosis of “Risk of Physical Trauma” is crucial for identifying patients who are at risk for physical trauma 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 physical trauma in at-risk patients.