00038 Risk Of Physical Trauma

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: 00038
Nanda label: physical trauma risk
Diagnostic focus: physical trauma
Approved 1980 • Revised 2013, 2017

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « risk of physical trauma ” is defined as: likely to suffer a serious physical injury of sudden appearance that requires immediate attention.

Risk factors

External factors

  • Absence of a device to request help
  • Absence of protection gate on the stairs
  • Absence of protection in the windows
  • Bathroom in very hot water
  • Bed in a very high position
  • Children in the front seat of the car
  • Defective devices
  • Delay in the ignition of gas devices
  • Demand device that does not work correctly
  • Easy access to weapons
  • Electrical danger
  • Exposure to corrosive products
  • Exposure to dangerous machinery
  • Radiotherapy exposure
  • Exposure to toxic chemicals
  • Flammable objects
  • Gas leaks
  • Fat in the kitchen
  • Ice Carámbanos hanging from the roofs
  • Inappropriate non -slip material in the soils
  • Inadequate lighting
  • Protection of inadequate heat sources
  • Inadequate stairs railings
  • Fuel stored inappropriately
  • Corrosive stored inappropriately
  • Inappropriate use of head protectors
  • Inappropriate use of support in the seats
  • Do not use the supports in the seats
  • Hall obstruction
  • Play with dangerous objects
  • Play with explosives
  • Wants of containers that stand out from the edge of the kitchen
  • Proximity to the passage of vehicles
  • slippery soil
  • Smoking in bed
  • Smoking near an oxygen source
  • Loose electrical cables
  • Handling Hiper Equipment
  • Unsure road
  • Usecure path
  • Use of cracked dishes
  • Use of fasteners
  • Use of carpets
  • Use of unstable chairs
  • Use of unstable stairs
  • Wear loose clothes near the flames

Internal factors

  • Cognitive dysfunction
  • Excessive emotional alteration
  • Postural balance deterioration
  • Inappropriate knowledge about safety precautions
  • Neurocomportal manifestations
  • Inadequate vision not resolved
  • Weakness

Risk population

  • People at economic disadvantage
  • People exposed to a neighborhood with high crime
  • People with a history of physical trauma

Associated problems

  • Decrease in eye-man coordination
  • Decrease in muscle coordination
  • Sensitivity disorders

Suggestions of use

  • Use a more specific diagnosis when possible.

Suggested alternative diagnostics

  • Aspiration, risk of
  • Falls, risk of
  • poisoning or poisoning, risk of
  • Transoperative postural injury, risk of
  • injury, risk of
  • Household maintenance, deterioration of

NOC Results

Note : Use the following noc results to evaluate the real presence of the diagnosis:

  • Severity of physical injury: severity of injuries caused by accidents and trauma
  • Tissue integrity: mucous skin and membranes: Structural integrity and normal physiological function of the skin and mucous membranes

Note : The following are some of the results that are related to trauma risk factors:

  • Safe at home: physical arrangements to reduce as much as possible the environmental factors that could cause physical damage or home injuries
  • Cognition: Ability to execute complex mental processes
  • Personal security behavior: personal acts of an adult to control behaviors that can cause physical injuries
  • Behavior for the prevention of falls: personal or family caregiver to minimize the risk factors that could precipitate falls in the personal environment
  • Balance: Ability to maintain body balance
  • Community violence level: incidence of violent acts, compared to local, state or national statistics

Evaluation objectives and criteria

  • • Demonstrates personal security behavior, which is manifested by (specifying 1 to 5: never, rarely, sometimes, often or usually):
  • • Store food to avoid its decomposition
  • • Use the seat belt properly
  • • Practice safe sex
  • • Use tools and machinery correctly
  • • Avoid high -risk behaviors
  • • Avoid smoking in bed
  • Other examples

    The patient will be able to:

    • • Avoid physical injuries
    • • Avoid alcohol abuse or recreational drugs
    • • Use solar filter

    NIC Interventions

    Note : For this very general diagnosis, various interventions may be needed to promote security and prevent trauma. Interventions differ to some extent if they are for patients in good condition or for institutionalized patients (for example, in a hospital).

    • Health Education: Development and offer of instruction and learning experiences to facilitate voluntary adaptation of behavior to improve the health of individuals, families, groups or communities
    • Teaching: infant security: Security instruction during the first year of life
    • Teaching: Safety of the Small Child: Security Instruction during the second and third years of life
    • Promotion of vehicular security: helps individuals, families and communities, to increase awareness about measures to reduce unintentional lesions in motorized and non -motorized vehicles
    • Risk identification: Analysis of possible risk factors, determination of health risks and prioritization of risk reduction strategies for a person or group
    • Environment management: Security: Control and manipulation of the physical environment to favor security
    • Reality orientation: Promote the patient’s awareness of his personal identity, time and environment
    • Fallen prevention: Establishment of special precautions with a patient at risk of drops lesions
    • Surveillance: Collection, interpretation and synthesis of patient data, continuously and with an end, to make clinical decisions
    • Surveillance: Security: Collection and analysis of information about the patient and the environment, continuously and with an end, for use in the promotion and maintenance of their safety

    Nursing Activities

    Valuations

    • • (NIC) Environment Management: Security:
      • Identify patient safety needs, based on the level of physical and cognitive functions and behavior history
      • Identify safety risks in the environment (for example, physical, biological and chemical)

    Patient and family education

    • • Instruct the patient and the family on specific security measures for the risk area
    • • Provide educational material related to trauma prevention strategies
    • • Provide information on environmental hazards and their characteristics (for example, stairs, windows, bail bolts, pools, streets, bars)

    Collaboration activities

    • • Channel to educational classes in the community (for example, RCP, first aid, or swimming)
    • • (NIC) Environment Management: Safety: Help the patient to move to a safer environment (for example, provide orientation for housing)

    Others

    • • (NIC) Environment Management: Security:
      • Modify the environment to reduce risks and dangers
      • Provide adaptation devices (for example, stools and handrails) to increase the safety of the environment
      • Use protection devices (for example, clamping systems, railings, blocked doors, bolts on the doors, bars and gates) to limit mobility or access to dangerous situations

    At home

    • • The above activities are appropriate for home use

    Babies and Children

    • • Recommend to parents that weapons are kept key and separately from ammunition
    • • Teach safety measures for children, such as maintaining flammable or toxic materials out of reach, using chairs for appropriate size children, and placing them correctly in the car
    • • Check if old homes have lead -based paint

    Older people

    • • Motivate the patient to perform exercises to strengthen muscles and improve balance
    • • Recommend the use of antiderrapant rugs, handrails that do not slip into bathtubs and showers; Maintain the mango of the pans towards the back of the stove when cooking; Use good lighting in corridors and stairs, and use night lights in bedrooms and bathrooms
    • • Recommend patients to keep medicines in their original jars or in a pillbox