00035 Risk Of Injury

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: 00035
Nanda label: injury risk
Diagnostic focus: injury
approved 1978 • Revised 2013, 2017

NANDA Nursing Diagnosis Definition

The Nanda nursing diagnosis « injury risk ” is defined as: likely to suffer an injury as a consequence of the interaction of environmental conditions with the adaptive and defensive resources of the person, which can compromise Health.

Risk factors

  • Cognitive dysfunction
  • Exposure to toxic chemicals
  • Immunization level in the community
  • Insufficient knowledge of modifiable factors
  • Malnutrition
  • Neurocomportal manifestations
  • Nosocomial agent
  • Pathogen exposure
  • Physical barriers
  • Contaminated nutritional source
  • Usecure transport system

Associated problems

  • Abnormal hematological profile
  • Alteration of psychomotor execution
  • Autoimmune diseases
  • Biochemical dysfunction
  • Effective dysfunction
  • Hypoxia
  • Immune system diseases
  • deterioration of primary defense mechanisms
  • Sensitivity disorders
  • Dysfunction of sensory integration

Suggestions of use

This label is very wide and includes internal risk factors such as altered coagulation factors and decreased hemoglobin. It is important to identify only those patients who have an extremely high risk of presenting this problem. All people are at risk to some extent of suffering accidents and injuries, but the label should only be used for those who require nursing interventions to prevent injuries.

Note : It could be useful to use the sensory perception tag as an etiology at risk of injury.

  • There are several diagnoses that describe the lesions more specifically:
  • Risk of falls, allergic response to latex, risk of allergic response to latex and risk of: asphyxiation, poisoning, trauma, vascular aspiration, adverse reaction to iodinated contrast media, deterioration of skin integrity, neonatal jaundice and syndrome of disuse. Whenever possible, these more specific labels should be used instead of
  • Risk of injury, since they offer more precise guidelines for nursing care. No major specifications are required, except
  • Risk of trauma that includes wounds, burns and fractures, as well as many other risk factors.
  • Some nursing professionals use the tag Risk of injury to describe the possibility of conditions such as malignant hyperthermia. Other times it is also used as a general description for the possibility of fetal suffering during childbirth.
  • It is more useful to describe these conditions as collaborative problems; However, for the nursing professional that does not use collaboration problems, this manual includes nursing objectives and interventions for these situations.

Suggested alternative diagnostics

  • Asphyxiation, risk of
  • Brocoaspiration, risk of
  • Falls, risk of
  • Infection, risk of
  • poisoning, risk of
  • latex, allergic response to
  • latex, risk of allergic response to
  • Household maintenance, deterioration of
  • Ineffective protection
  • bleeding, risk of
  • Trauma, risk of
  • Self -directed violence, risk of

NOC Results

  • Safe at home: physical arrangements to reduce as much as possible the environmental factors that could cause physical damage or home injuries
  • Personal security behavior: personal acts of an adult to control behaviors that can cause physical injuries
  • Risk Control: Personal actions to prevent, eliminate or reduce health threats that can be modified
  • Risk detection: personal actions carried out to identify threats to the health of the individual
  • Sensory function: Degree in which an individual feels correctly tactile stimulation, sounds, proprioception, taste, smell and visual images
  • Severity of physical injury: severity of injuries caused by accidents and trauma
  • Incidence of falls: how many times an individual falls
  • Tissue integrity: mucous skin and membranes: Structural integrity and normal physiological function of the skin and mucous membranes
  • Protection against abuse: protection of itself and other people dependent against abuse

Evaluation objectives and criteria

  • The risk of injury is reduced, as evidenced by personal safety behavior, risk control and a safe atmosphere in the home
  • Risk control is demonstrated, as manifested by the following indicators (specify 1-5: never, rarely, once, often or usually):
    • Watch the environmental and behavioral risk factors
    • Design effective risk control strategies
    • Follow the chosen risk control strategies
    • Modify lifestyle to reduce risks

Other examples

The patient and family will be able to:

  • Provide a safe environment (by eliminating disorder and spills, placing handrails, and using antiderrapant rugs and grip bars in the bathroom)
  • Identify the risks that increase the possibility of injuries
  • Avoid physical injuries

Parents will be able to:

  • Recognize and monitor the risk of abuse
  • Monitor playmates, caregivers and other social contacts
  • Detect signals that indicate participation in gangs and other high -risk social behaviors

NIC Interventions

  • Support for protection against abuse: identification of actions and high -risk dependence relationships to prevent greater suffering of physical or emotional damage
  • Risk identification: Analysis of possible risk factors, determination of health risks and prioritization of risk reduction strategies for a person or group
  • Allergy Management: Identification, treatment and prevention of allergic responses to food, medicines, insect bites, contrast material, blood and other substances
  • Pressure management: pressure reduction on body parts
  • Environment management: Security: Control and manipulation of the physical environment to favor security
  • Prevention measures for latex: Reduction of the risk of a systemic reaction to latex ( note : If the patient requires prevention measures for latex, the risk diagnosis of or the risk of or the risk of or should be used Real of latex allergy response instead of risk of injury)
  • Fall prevention: Use of special precautions with a patient at risk of drops lesions ( note : If a patient requires fall prevention, the author recommends using the nursing diagnosis risk of falls)
  • Prevention of malignant hyperthermia: prevention or reduction of a hypermetabolic response to pharmacological medicines used during surgery. ( Note : If the patient requires malignant hyperthermia prevention, use a diagnosis of hyperthermia risk nursing instead of injury risk)
  • Prevention of sports injuries: Young: Reduction of the risk of sports injuries in young athletes
  • Physical restriction: application, surveillance and elimination of mechanical or restriction manuals that limit the physical mobility of the patient
  • Surveillance: Security: Collection and analysis of information in a certain and continuous way, on the patient and the environment, for use in the promotion and maintenance of their safety

Nursing Activities

  • As this diagnosis is so wide, nursing activities vary greatly depending on the etiology of the problem. It is not possible to provide all possible nursing activities that could be used for this diagnosis.

Valuations

  • Identify the factors that affect security needs, such as changes in mental state, degree of poisoning, fatigue, maturation age, medications and motor or sensory deficiencies (for example, way of walking, balance)
  • Identify environmental factors that create falls risk (for example, slippery soils, carpets, stairs, windows, swimming pools)
  • Verify that the patient wears clothes that prevents him from moving easily, if he has cuts, burns or bruises
  • Review the obstetric history to collect relevant information that can influence induction, such as gestational age and the duration of anterior delivery, as well as contraindications such as full placenta, classical uterine incision and structural deformities of the pelvis

Patient and family education

  • Indicate the patient to be careful when using thermotherapy devices
  • Offer educational material related to the strategies and measures necessary to avoid injuries

Collaboration activities

  • Channel to educational classes in the community

Others

  • Reorient the patient to place it again in reality and the immediate environment, if necessary
  • Help the patient wandering, according to proceed
  • Offer help for walking (cane, walker)
  • Use heating devices with caution to avoid burns in patients with sensory deficiencies
  • Use an alarm to notify the caregiver when the patient gets out of bed or leaves the room
  • If necessary, use physical supports to limit the risk of falls
  • Place a bell or light to call all the time, and leave it available to the dependent patient
  • Indicate the patient to request help to move, if required
  • Eliminate environmental hazards (for example, provide adequate lighting)
  • Do not make unnecessary changes in the physical environment (for example, placement of furniture)
  • Ensure that the patient triggers adequate shoes (for example, of antiderrapant soles, with safe closures)

At home

  • Identify the factors that affect security needs such as changes in mental state, degree of poisoning, fatigue, maturation age, medications and motor or sensory deficiencies (for example, way of walking, balance)
  • Identify environmental factors that create falls risk (for example, slippery soils, carpets, stairs, windows, swimming pools)
  • Inform about environmental hazards and their characteristics (stairs, windows, closet locks, pools, streets, doors)
  • Teach the patient and family techniques to avoid home injuries, specify these techniques
  • Do not make unnecessary changes in the physical environment (for example, placement of furniture)

Babies and Children

  • Start a fetal electronic monitoring as part of care during childbirth, according to the protocols of the institution
  • Raise the railing of the crib when there is no caregiver
  • In the case of children older enough to climb the railings, use a crib with a network or other protection
  • Notify parents about the need to control children when they are near the water (in the bathtub)
  • Instruct parents about fire regulations and burns (always supervise children in the kitchen; turn the handles of the kitchen utensils towards the back of the stove)
  • Instruct parents about the need for a safe game (for example, take a helmet when riding a bicycle)
  • Teach parents and children the safe management of objects that can cause injuries (knives, knives, weapons, etc.)

Older people

  • Indicate the patient to wear glasses, auditory assistants and walking devices; Make sure these grants work properly, are well placed, etc.
  • Check the orthostatic hypotension
  • Determine if the patient can drive safely and if their night vision is suitable for driving at night
  • Monitor and teach the client to control the level of blood glucose
  • Deliver a medical identification bracelet, if necessary