Home » Nursing Care Plans » Nursing Diagnosis » Risk for Injury & Patient Safety Nursing Care Plan and Management

Risk for Injury & Patient Safety Nursing Care Plan and Management

Updated on
By Gil Wayne BSN, R.N.

This nursing care plan and management guide can assist nurses in providing care for patients who are at risk for injury. Get to know the nursing assessment, interventions, goals, and nursing diagnosis to promote patient safety and prevent injury.

Table of Contents

What is Patient Safety?

Patient safety, according to the World Health Organization, is defined as a framework of organized activities that creates cultures, processes, procedures, behaviors, technologies, and environments in healthcare that consistently and sustainable lower risks, reduce the occurrence of avoidable harm, and makes error less likely and reduces its impact when it does occur. 

Healthcare-related injuries greatly impact the well-being of the patient. On average, it is estimated one in 10 patients is subject to an adverse event while receiving hospital care in high-income countries. About 134 million adverse events occur due to unsafe care in hospitals in low- and middle-income countries, contributing to around 2.6 million deaths every year. Recent estimates suggest that the social impact of patient harm can be valued at 1 trillion to 2 trillion U.S. dollars per year (WHO Global Patient Safety Action Plan 2021-2030). 

Nurses play a major role in providing effective, safe, and patient-centered care and implementing favorable injury prevention programs in the healthcare setting. 

Safety First: A Nurse’s Guide to Promoting Safety Measures Throughout the Lifespan

By Iris Dawn Tabangcora

Safety is a fundamental concern of all nurses. From bedside to the community, nurses see to it that accidents and injuries are prevented. From a simple act of reminding patients to call them whenever they need assistance to preparing emergency equipment, nurses demonstrate the act of being protectors of patients under their care.

Despite nurses’ attentiveness, accidents cannot be totally avoided. Part of nurses’ responsibilities is to assist those who have been injured due to vehicle accidents, drowning, fires, and poisoning. There is a great need for nurses to have a high awareness of the elements of a safe environment. Moreover, accidents are usually caused by human conduct. Thus, accidents can be prevented.

Here is a guide to promoting safety measures throughout the lifespan:

The first year of life is prone to accidents. It is not surprising that accidents are the leading cause of death in infants. Being dependent on others for care and them being oblivious to hints of danger make them vulnerable to injuries.

Common accidents during infancy include burns, choking and suffocation, falls, and poisoning. Here’s how nurses and parents alike can promote a safe environment for newborns and infants:

  • Use a federally approved car seat at all times. It should be in the back seat, facing backward.
  • Never leave the infant unattended on a raised surface.
  • Check the temperature of the baby’s bath water and formula prior to using.
  • Hold the infants upright during feeding. Do not prop the bottle. Cut food into small pieces, and do not feed the infants peanuts or popcorn.
  • Provide large soft toys with no small detachable or sharp-edged parts.
  • Cover electric outlets. Coil cords out of reach.
  • Place plants, household cleaners, and wastebaskets out of reach. Lock away potential poisons (e.g. medicines, paints, and gasoline).

Toddlerhood is years of curiosity. Therefore, toddlers would feel and taste anything that catches their fancy. Nurses that work closely with toddlers and parents who are raising one know all too well that these children need constant supervision and protection. They are experiencing the world and are usually fascinated by pools and busy streets, two of which are just some of the potential dangers lurking in the corner.

Here are some ways that can promote safety to toddlers:

  • Continue using federally approved car seats at all times. Place children in the back seat when traveling in a car.
  • Teach children not to put things in the mouth, including pills (unless given by parent).
  • Keep objects with sharp edges (e.g., furniture, knives) out of children’s reach.
  • Place hot pots on back burners with handles turned inward.
  • Keep cleaning solutions, insecticides, and medicines in locked cupboards.
  • Supervise toddlers in the tub.
  • Obtain a low-lying bed when the child begins to climb.
  • Cover outlets with safety covers or plugs.

Children in this age are unusually active but are often very clumsy. This is the perfect age for safety education (e.g. crossing the streets, meaning of traffic signals, riding bicycles). Careful surveillance must continue because preschoolers are still not self-reliant in matters of safety. Their cognitive and motor skills increase quickly so safety measures should keep up with the acquisition of new skills.

Here are the safety measures for children in this stage:

  • Do not allow children to run with candy or other objects in the mouth.
  • Teach children not to put small objects in the mouth, nose, and ears.
  • Remove doors from unused equipment such as refrigerators.
  • Always supervise preschoolers in crossing streets and begin safety teaching about obeying traffic signals and looking both ways.
  • Teach children to play in safe areas. Teach them about the dangers of playing with matches and playing near charcoal, fire, and heating appliances.
  • Teach children to avoid strangers and keep parents informed of their whereabouts.
  • Teach preschoolers not to walk in front of swings and not to push others off playground equipment.

Children at this stage now think before they act. They are sensitive to peer pressure, but school-age children respond to rules. They like fantasy and magical thinking and are usually known for imitating adult actions. They are especially prone to injuries caused by outdoor activities and recreational equipment.

One can promote safety for school-age children by sharing this bulleted list:

  • Teach safety rules for recreational and sports activities (e.g., never swim alone, wearing a life jacket in a boat, and wearing a helmet and protective pads as needed).
  • Supervise contact sports and activities in which children aim at a target.
  • Teach children safe ways to use a stove, garden tools, and other equipment.
  • Teach children not to play with fireworks, gunpowder, or firearms.
  • Teach the children the health hazards of smoking. If you smoke, stop.
  • Teach children the effects of drugs and alcohol on judgment and coordination.

Teenager’s level of responsibility, common sense, and ability to resist peer pressure should be assessed. This is also the time when some can obtain their driver’s license. Other than that, sports injuries, suicide, and homicide are just some of safety threats nurses and parents should be concerned when dealing with adolescents.

Here are safety measures for adolescents:

  • Have adolescents complete a driver’s education course, and take practice drives with them in various kinds of weather.
  • Set firm limits on automobile use (e.g., never drive under the influence of drugs and alcohol).
  • Encourage the use of proper equipment when participating in sports.
  • Teach safety measures for use of power tools.
  • Inform adolescents of the dangers of drugs, alcohol, and unprotected sex. Include teaching about date rape prevention and defense.
  • Watch out for mood and behavior changes of this age group. It is important to maintain open communication with adolescents.
  • Set a good example of behavior that the adolescent can follow.

This age group is especially at risk for vehicle accidents, suicide, and exposure to natural radiation, drowning, and firearms. The nurse can foster safety by remembering these things:

  • Reinforce motor vehicle safety.
  • Remind to repair potential fire hazards, such as electrical wiring.
  • Discuss evaluating the possibility of workplace injuries or death while making career decisions.
  • Discuss avoiding excessive sun radiation.
  • Encourage those who are unable to cope to seek counseling.

The injury rate of middle-aged adults are affected by changing physiologic factors and personal and work-related responsibilities. Here’s how nurses can help them protect themselves:

  • Reinforce motor vehicle safety.
  • Make certain stairways are well lighted and uncluttered.
  • Equip bathrooms with hand grasps and non-skid bath mats.
  • Test smoke detectors and fire alarms regularly.
  • Follow safety precautions when using machinery.

One of the major concerns in taking care of older people is injury prevention. They are particularly at risk for accidents and injuries because of their limited vision, slow reflexes, and brittle bones. Simple activities like climbing stairs and driving a car would require a lot from them. They have failing memories and are often prone to wandering.

Nurses can make elders have a safe home environment through these reminders:

  • Ensure eyeglasses are functional.
  • Ensure appropriate lighting.
  • Keep environment tidy and uncluttered.
  • Mark doorways and edges of steps as needed.
  • Wear shoes or well-fitted slippers with non-skid soles.
  • Provide assistance with ambulation as needed.
  • Monitor gait and balance as well as activity tolerance. Also, monitor orientation and alertness status.
  • Keep bed in a low position.
  • Install grab bars in bathroom. Provide raised toilet seat.
  • Encourage annual or more frequent review of all medications prescribed.

Causative factors may include

The following are factors that may put a patient at risk for injury or harm:

  • Abnormal blood profile can encompass conditions such as anemia, leukopenia, and thrombocytopenia, which heighten the risk of bleeding, infection, and bruising. For instance, a patient with anemia may be more prone to bleeding from minor cuts.
  • Impaired psychomotor performance involves diminished coordination, slowed reaction time, and difficulties with balance and motor skills, often observed in conditions like Parkinson’s disease, traumatic brain injury, or due to certain medications.
  • Impaired sensory function includes conditions like blindness, deafness, and loss of sensation, which increase the likelihood of falls, accidents, and injuries. For instance, a blind patient may have a higher risk of tripping and falling.
  • Changes in cognitive function, as seen in dementia, delirium, and Alzheimer’s disease, elevate the risk of falls, accidents, and injuries. For example, a patient with dementia may be more prone to wandering off and becoming lost.
  • A weakened immune system resulting from conditions like cancer, HIV/AIDS, or undergoing chemotherapy raises the susceptibility to infections. For example, a patient with cancer is more susceptible to developing pneumonia.
  • Physical barriers, such as stairs, narrow doorways, and uneven floors, increase the risk of falls and injuries. For instance, a patient using a wheelchair may be more prone to falling if they encounter stairs.
  • Improper use of assistive devices, such as wheelchairs, canes, or crutches, which may not be properly sized or used incorrectly, raises the risk of falls and injuries. For example, a patient using a wheelchair that is too small for them may be more likely to fall out of it.
  • Engaging in an unsafe mode of transportation, such as driving without a seatbelt, riding a motorcycle without a helmet, or walking/biking in the street, increases the risk of injury or death. For example, a patient who does not wear a seatbelt while driving is more susceptible to injuries in a car accident.
  • Lack of knowledge regarding environmental hazards, including unfamiliarity with toxic chemicals, incorrect usage of assistive devices, or lack of knowledge on fall prevention, heightens the risk of injury or death. For instance, a patient unaware of the dangers of toxic chemicals may be more likely to be exposed to them.

Nursing Diagnosis

Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with patient safety and risk for injury based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities. However, if you still find value in utilizing nursing diagnosis labels, here are some examples to consider:

  • Risk for Injury related to sensory impairment (e.g., visual or auditory deficits)
  • Risk for Injury related to cognitive impairment (e.g., dementia, delirium)
  • Risk for Injury related to medication side effects (e.g., dizziness, orthostatic hypotension)
  • Risk for Injury related to compromised skin integrity (e.g., in patients with diabetes or vascular insufficiency)
  • Risk for Injury related to invasive procedures (e.g., surgery, catheterization)
  • Risk for Injury related to impaired judgment secondary to psychiatric conditions (e.g., schizophrenia, bipolar disorder)
  • Risk for Injury related to environmental hazards (e.g., cluttered living space, poor lighting)

Goals and outcomes

Here are the common goals and expected outcomes:

  • Within 8 hours of nursing intervention and treatment, the patient will determine the factors that increases their risk for injury and will demonstrate behaviors to avoid injury.
  • Within 4 hours of nursing interventions and teaching, the patient will remain free of injuries.

Nursing assessment and rationales

A detailed nursing assessment guide identifies the individual’s risk for injury and assists with the clinical decision by indicating which interventions should be included in the care plan.

1. Determine the client’s age, developmental stage, health status, lifestyle, impaired communication, sensory-perceptual impairment, mobility, cognitive awareness, and decision-making ability.
These factors play a role in the client’s ability to keep themselves safe from injury. Nurses must thoroughly assess each of these factors when formulating a plan of care or teaching the clients about safety measures. These factors are explained in detail below: 

  • 1.1. Evaluate age and developmental stage.
    Infants and toddlers usually explore their surroundings using their senses (seeing, smelling, touching, and tasting) by placing items or objects in their mouths that put them at risk for choking. While older individuals have reduced sensory acuity and gait problems, which can contribute to the incidence of injury.
  • 1.2. Assess for changes in health status and cognitive awareness. 
    A change in health status may increase a client’s risk of injury. For example, a postoperative patient may experience confusion, disorientation, and memory loss putting them at risk for falls/injury. Clients under certain medications (e.g., anti seizures, depressants, benzodiazepines, hypnotics, opioids) may impair one’s judgment.
  • 1.3. Assess the client’s lifestyle. 
    Factor in the client’s lifestyle when identifying risk for injury. For example, unsafe working conditions, settling in a community with high crime rates, access to guns or weapons, unavailable safety equipment due to lack of funds, and misuse of prescription drugs. 
  • 1.4. Assess for impairment in communication. 
    Communication problems such as language barriers and speech and hearing difficulties may affect the client’s ability to process information placing them at risk to experience an adverse event in the hospital.
  • 1.5. Assess for sensory-perceptual impairment.
    Loss or impairment of senses (vision, taste, hearing, smell, and touch)  may affect how a person responds to environmental stimuli that place them at risk for injuries and falls. For example, a client with an olfactory impairment might be unable to detect a gas leak, or an individual with a deteriorating vision may be prone to slip or fall. 

2. Assess the client’s ability to ambulate and identify the risk for falls.
Alterations in mobility secondary to muscle weakness, paralysis, poor balance, and lack of coordination increase the risk of falls. The Morse Fall Scale (MFS) is a simple fall risk assessment tool commonly used among health care facilities. It uses a point scale system that checks on the six variables (history of falling within the three months, secondary diagnosis, use of assistive devices, IV/heparin lock, gait/transferring, and mental status. An MFS score of 0-24 (no risk) means no interventions are needed. A score of 25-50 (low risk) signifies that standard fall prevention interventions should be initiated. A score of >51 or high risk means that high-risk fall prevention interventions must be implemented (Lohse et al., 2021). 

Please visit our care plan and nursing care management guide for a complete assessment and interventions for Risk for Falls. 

3. Note the client’s age and observe for signs of physical injury (bruises, burns or scalds, history of fractures, lacerations, bite marks, social withdrawal, fearfulness). 
These are indicators of a possible intentional injury or abuse that must be thoroughly assessed to ensure the client receives medical attention, is referred for additional support, and prevents further harm. All healthcare providers have a moral and legal obligation to identify these kinds of injuries, abuse and refer them immediately to the social welfare or Child Protective Services (CPS) (Gonzalez et al., 2021).

4. Conduct safety assessment in the client’s home or care setting. 
Nurses perform an environmental risk assessment to determine the presence of objects or items (e.g., cord, hooks) that could potentially be used in suicidal hanging. Therefore, it should be removed to ensure the client’s safety. 

5. Check on the home environment for threats to safety.
Patients experiencing impaired mobility, impaired visual acuity, and neurological dysfunction, including dementia and other cognitive functional deficits, are at risk for injury from common hazards. Older individuals with a history of falls or functional impairment associate their slips, trips, or falls inside the home due to household hazards (Fares, 2018). The client’s home may be inspected for the following that puts them at risk for injury: throw rugs, clutter, improper storage of cleaning products or chemicals, improper storage of medications, dim lighting, etc. Check out the Recommended Resources section below for a checklist by the CDC of common hazards found in homes.

6. Assess whether exposure to community violence contributes to risk for injury.
Exposure to community violence has been associated with increases in aggressive behavior and depression. Some health care facilities participate in community-building programs that address the needs of vulnerable individuals and prioritize violence prevention or programs that can help minimize some of the causes of violence (Van Den Bos et al., 2017).

Nursing interventions and rationales

The following are the therapeutic nursing interventions for patients at risk for injury:

1. Guide the patient to their surroundings. Put the call light within reach and teach how to call for assistance.
The patient should be familiar with the layout of the environment to prevent accidents from happening. Items that are too far from the patient may cause hazards. 

2. Enhance safety through the use of medical alarm systems. Recognize and watch out for alarm fatigue.
Medical alert systems are triggered to alert an emergency that a patient is experiencing physiological changes necessitating immediate treatment. However, alarm fatigue, a common safety issue among health facilities, occurs when an excessive number of monitor alarms overwhelms the health care provider, resulting in missing true clinically important alarms. According to the National Patient Safety Goals 2022, to reduce alarm fatigue and other issues, health care organizations should treat alarm system safety as a priority, determine the most important alarm signals to attend, establish systematic guidelines for handling alarms, and provide education and training to health care members in safe alarm management (The Joint Commission, 2022).

3. Avoid the use of physical and chemical restraints. Obtain a health care provider’s order if restraints are needed.
Restraints can cause injuries such as strangulation, asphyxiation, trauma, or head injury. If restraint is needed, ethical principles of proportionality and purposefulness should be applied (Chuang et al., 20. The principle of proportionality states that the level of coercive measures is limited to what is least allowed for a patient’s condition, and the principle of purposefulness states that coercive measure is applied if a specified purpose has been established beforehand (Hammervold et al., 2019).

4. Utilize alternatives to restraints that can be used to prevent falls and injuries. 
Alternatives to restraints may include alarm systems with ankle or wrist bracelets, alarms for bed or wheelchairs, close and frequent monitoring of the patient, locked doors to the unit, keeping the bed low, etc.

5. If a patient is notably disoriented, consider using a special safety bed that surrounds the patient. If a patient has a traumatic brain injury, use the Emory cubicle bed.
Special beds can be an efficient and useful alternative to restraints and help keep the patient safe during periods of confusion and anxiety. Enclosure beds that require a health care provider’s order can also be used to prevent falls and to provide a safer environment for clients who are confused, agitated, or restless but are contraindicated for clients who are combative and claustrophobic (Walters, 2017).

6. If a patient has a new onset of confusion (delirium), render reality orientation when interacting with them. Have family or significant other bring in familiar objects, clocks, and watches from home to maintain orientation. If a patient has chronic confusion with dementia, use validation therapy that reinforces feelings but does not confront reality.
Reality orientation can help limit or decrease the confusion that increases the risk of injury when the patient becomes agitated. Validation therapy is a useful approach and form of communication to a person with a mild-moderate stage of dementia. It relieves clients’ stress and minimizes behavioral disturbances (Berg-Weger & Stewart, 2017).

7. Ask family or significant others to be with the patient to prevent the incidence of accidental falling or pulling out tubes.
This is to prevent the patient from accidental injury, falling, or pulling out tubes. Parents of hospitalized children have a big role in ensuring safety and protecting their children against potential medical errors (Duhn et al., 2020).

8. Avoid extremes in temperature (e.g., heating pads, hot water for baths/showers).
Patients with decreased cognition or sensory deficits cannot discriminate between extremes in temperature. Age-related physiological changes (e.g., loss of dermal appendages, dermal atrophy, and loss of insulating subcutaneous fat) and cognitive conditions such as dementia, peripheral artery disease, and diabetes that affect a person’s mobility and judgment are prone to burn injury (Sasor & Chung, 2019). 

9. Place the patient in a room near the nurses’ station.
Moving the client’s room closer to the nurse station allows the health care provider to closely observe patients at high risk for injury and falls and promptly provide interventions. 

10. Validate the patient’s feelings and concerns related to environmental risks.
Validation lets the patient know that the nurse has heard and understands the information and concerns. It also helps promote the nurse-patient relationship.

11. For patients with visual impairment, educate them and their caregivers to use labels with bright colors such as yellow or red in significant places in the environment that must be easily located (e.g., stair edges, stove controls, light switches).
Lighting an unfamiliar environment helps increase visibility if the patient must get up at night. Using bright colors and assigning them with objects allows patients with vision impairment to safely navigate the environment since bright colors are easier to recognize visually.

12. Perform handwashing and hand hygiene
Hand hygiene is the single most effective technique to prevent infection.

Interventions promoting patient safety through proper identification

1. Establish (or follow agency protocols) protocols for identifying clients correctly.
Utilize at least two identifiers (such as name, date of birth, assigned identification number, or phone number) to verify the client’s identity during hospital admission or transfer and before administering medications, blood products, or nursing care. This will improve the reliability of the client’s identification system and prevent nursing errors. It will ensure safety to all patients, especially when verbal communication is not possible (e.g., newborn, unconscious, or confused patients).

2. Identify clients correctly.
Utilize at least two identifiers (such as name, date of birth, medical record number, or phone number) to verify the client’s identity during hospital admission or transfer and before administering medications, blood products, or when providing treatment or when providing treatment procedures. This will improve the reliability of the client’s identification system and prevent the incidence of misidentification. 

3. Provide medical identification bracelets for patients at risk for injury.
Such identification is vital for patients at risk for injury, especially those with dementia, seizures, or other medical disorders. Acknowledgment of the condition can help the nurse implement appropriate interventions to promote the patient’s safety. 

4. Establish a standardized system when identifying clients who lack identification and differentiating the identity of clients with a similar name.
Further clarification of details such as date of birth or address should be done to ensure the health care provider is handling the right patient. Furthermore, when accessing a client’s record through a computer, an alert should be activated if another client has the same name. 

5. Use non-verbal approaches such as biometrics when identifying unconscious or confused patients.
If verbal communication is not possible, using a biometric positive patient ID can prevent client misidentification.

6. Label blood and other specimen containers in front of the patient.
To ensure accurate identification, each specimen container must be labeled properly in the patient’s presence containing important information: patient’s full name, date and time of collection, and collector’s identification. Barcoding is an effective approach in minimizing identification errors on the patient specimens and laboratory testing in hospital settings and is suggested as an evidence-based best practice (Snyder et al., 2012).

7. Use active communication if possible during patient identification.
Ask the patient to state their name verbally and date of birth as opposed to the “yes” or “no” question in confirming patient identification before the start of any procedure (Beyea, 2003).

Interventions preventing the risk of injury due to medication errors

1. Administer medications using the “10 Rights of Medication Administration“. 
Understanding the 10 Rights of Drug Administration can help prevent many medication errors

You can learn more about the “10 Rights of Medication Administration” here.

2. Put a label on all medications, drug containers (medicine cups, bottles, syringes, basin), or other solutions on or off the sterile area.
Any medications or solutions removed from the original packaging and transferred to another container should be properly labeled to be considered safe (Saufl, 2009). Discard all unlabeled medications or solutions. Label medications or solutions that will not be immediately given. The label should contain the following information: drug name or solution, concentration, amount of medication, diluent name, and volume.

3. Ensure accurate and complete medication information transfer from admission, transfer, and discharge.
Medication reconciliation compares the medications a client is currently taking with newly prescribed medications (Barnsteiner, 2008). This reconciliation is designed to prevent different medication discrepancies such as contraindications, omissions, duplications, incorrect doses or dosage forms, and adverse drug events (ADEs). Medication reconciliation involves five steps:

  1. Obtain a complete list of medications the patient is currently taking
  2. Obtain a list of medications to be prescribed
  3. Compare and reconcile all medications identified
  4. Make clinical judgment based on the comparison
  5. Communicate the updated list to the patient and other health care team involved in the care.

A written discharge instruction about medications is given to the patient, family, or caregiver explaining the medication name, purpose, dose, frequency, and route. 

4. Provide extra caution to clients receiving anticoagulant therapy.
This consideration is applied for patients undergoing long-term anticoagulant therapy such as pulmonary embolism, atrial fibrillation, deep vein thrombosis, and mechanical heart valve implant. Prolonged anticoagulant therapy may result in bleeding risk and other adverse drug events due to complex dosing, inadequate monitoring, and inconsistent patient compliance.

5. Review the client’s medication regimen for possible side effects and potential interactions that may increase the risk of injury.
Polypharmacy or the use of multiple medications (sedatives, psychotropics, hypoglycemics, antihypertensive, anti-arrhythmic, diuretics, and anticonvulsants) puts the patient at a greater risk for gait disturbances, falls, and burn-related injuries among older individuals (Esechie, Masel, et al., 2019). 

Interventions to prevent trauma or injury during seizures.

1. Teach patients and significant others to identify and familiarize warning signs for seizures. Educate on how to care for patients during and after seizure attacks.
Enables patients to protect themselves from injury and recognize changes requiring healthcare providers’ notification and further intervention. Knowing what to do when a seizure occurs can prevent injury or complications and decrease significant others’ feelings of helplessness.

2. Monitor and record type, onset, duration, and characteristics of seizure activity.
Seizure activity should be documented to guide the treatment and differentiation of the type of seizure and recognition of triggering factors. 

3. Avoid using thermometers that can cause breakage. Use a tympanic thermometer when taking a temperature reading.
Reduces the risk of a patient biting and breaking the glass thermometer if a sudden seizure occurs. 

4. Uphold strict bedrest if prodromal signs or aura experienced. 
Patients may feel restless or need to ambulate or even defecate during the aural phase, thereby inadvertently removing themselves from a safe environment and easy observation. 

5. Turn head to side during seizure activity to allow secretions to drain out of the mouth, minimizing the risk of aspiration and suction airway as indicated. 
Helps keep airway patency and reduces the risk of oral trauma but should not be “forced” or inserted when teeth are clenched because dental and soft-tissue damage may result.

6. Support head, place on a padded area, or assist to the floor if out of bed. 
Supporting the extremities lessens the risk of physical injury when the patient lacks voluntary muscle control.

7. Put away all possible hazards in the room, such as razors, medications, and matches.
This prevents the patient from any unpleasant experience due to hazardous objects. Medicines should be properly stored up and away and out of sight where a child cannot reach them (Budnitz & Salis, 2011).

8. Do not restrain the patient. 
Instead of restraining, support the patient’s movement gently during seizure activity to help prevent injury caused by flailing.  

9. Monitor and document antiepileptic drug levels, corresponding side effects, and frequency of seizure activity.
A standard therapeutic level may not be optimal for an individual patient if untoward side effects develop or seizures are not controlled.

10. Maintain a lying position on, flat surface. Turn head to side during a seizure to help maintain the tongue from blocking the airway. Remove any objects near the patient.
Helps maintain airway patency and protect the patient’s body from injury.

11. Loosen clothing from neck or chest and abdominal areas; suction as needed.
Constrictive clothing may cause trauma and hypoxia to the patient.

12. Supervise supplemental oxygen or bag ventilation as needed postictally.
May lessen cerebral hypoxia resulting from decreased circulation or oxygenation secondary to vascular spasm during a seizure.

13. Enforce education about the disease. 
Review pathology and prognosis of condition and lifelong need for treatments as indicated; discuss patient’s particular trigger factors (flashing lights, hyperventilation, loud noises, video games, TV viewing); know and instill the importance of good oral hygiene and regular dental care; review medication regimen, the necessity of taking drugs as ordered, and not discontinuing therapy without health care provider’s supervision; include directions for a missed dose.

Visit our nursing care management guide for patients with seizures here. 

Interventions preventing the risk of injury due to impaired mobility

1. Aid the patient when sitting and standing up from a chair or chair with an armrest. Limit the use of wheelchairs and Geri-chairs except for transportation as needed.
Patients are likely to fall when left in a wheelchair or Geri-chair because they may stand up without locking the wheels or removing the footrests. 

2. To ensure propulsion with legs or arms and the ability to reach the floor, ensure that the chair or wheelchair fits the patient’s build, abilities, and needs, eliminating footrests and minimizing problems with shearing.
The seating system should fit the patient’s needs so that the patient can move the wheels, stand up from the chair without falling, and not be harmed by the chair or wheelchair. Wheelchairs are often prescribed to clients without the proper guidance of an occupational therapist or another specialist that can conduct a clinical assessment and make recommendations for proper seating and wheeled mobility. As a result, many residents have poorly fitting wheelchairs that can create additional health, mobility, and function issues. 

3. Limit the use of wheelchairs as much as possible because they can serve as a restraint device. Most patients in wheelchairs have limited ability to move.
Only use restraint devices as a last resort and only when the potential benefits outweigh the potential harm. A poorly-fitted wheelchair risks shoulder injuries from continuous stress and sacral or ischial breakdown (Sabol, 2006).

4. Use assistive devices (pillows, gait belts, slider boards) during transfer.
Transferring a patient is considered a high-risk maneuver due to the possible risk of injury to the client and the health care provider. The use of assistive devices such as slider boards is helpful among clients with mobility problems to be safely transferred between a bed and chair. It is commonly used for clients with balance and strength deficits in lower extremities, paraplegia, and amputated lower extremities.

5. Consider the principles of proper body mechanics before any procedure, such as raising the head of the bed and tucking elbows in.
Proper body mechanics minimizes the risk of muscle and bone injury and promotes body movement to facilitate physical mobility without muscle strain and without using excessive energy (Kochitty & Devi, 2015).

6. Coordinate with a physical therapist for strengthening exercises and gait training to increase mobility. Contact occupational therapists for assistance with helping patients perform ADLs.
Gait training in physical therapy has been proven to prevent falls effectively. Safety is accomplished from the collaborative efforts by both individuals that provide direct or indirect care to clients and the healthcare system. 

7. Educate patients about safety ambulation at home, including using safety measures such as grab bars in the bathroom, use of non slip, well-fitting footwear, and encourage clients to request assistance. Home safety should be assessed, discussed with clients and caregivers, and considered frequently when making decisions regarding the future of the client’s care towards maximizing their health outcomes. Educating the client and the caregiver about the modification of the home environment is essential in the promotion of functional and independent living and the prevention of injury.

Client Teaching: Preventing Back Injuries

The lower back plays a crucial role in maintaining balance and daily activities. Damage to it can affect the hips and extremities. Thus, preventing lower back injuries is crucial. Several factors heighten the risk of lower back injuries, including bad postures and conditions that strain the lumbar like obesity and wearing high heels. Weak back muscles, often due to sedentary lifestyles, also increase risk. Here are some tips for back injury prevention:

  1. Maintain Good Posture:
    • Stay mindful of body alignment in daily activities.
    • When standing, keep the head and shoulders aligned. For prolonged standing, shift your weight or prop up one foot periodically.
    • Sit straight, ensuring your back is supported, and change your position every 30 minutes.
  2. Know Your Lifting Limits:
    • Avoid lifting over 51 pounds.
    • Use your leg and arm muscles for lifting.
    • For heavier loads, use aids or seek help.
    • Everyone, regardless of age or strength, should be cautious when lifting.
  3. Follow Lifting Best Practices:
    • Keep your center of gravity close to the object you’re lifting.
    • Maintain a wide base of support.
    • Avoid twisting when lifting.
    • Whenever possible, push or pull objects rather than lifting them.
  4. Exercise Regularly:
    • Strengthen core muscles to support your back.
    • Cardio exercises enhance blood flow to the spine, nourishing and hydrating it.
  5. Minimize Accident Risks:
    • Wear low-heeled, non-skid shoes for better balance and support.
  6. Boost Overall Health:
    • Better spine health is linked to overall body health.
    • Stay hydrated, limit alcohol, quit smoking, and ensure you get quality sleep.

Resources you can use to improve your nursing care for patients with risk for injury. 

  1. Global Patient Safety Action Plan 2021-2030. A publication by the World Health Organization that helps countries create and develop their framework and national action plans on patient safety. Includes interesting facts and the impact of unsafe care. 
  2. PROTECT Initiative (PRevention of Overdoses and Treatment Errors in Children Task Force). If you want to learn more on how to improve and promote safety for children and prevent medication overdoses. 
  3. Checking for Home Safety. A useful checklist of hazards that a patient or a nurse could use to promote safety at home. 
  4. National Patient Safety Goals by The Joint Commission. Great resource for organizations to address specific areas concern in regard to patient safety.

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care 
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health 
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.

See also

Other recommended site resources for this nursing care plan:

References and Sources

Recommended references and sources to further your reading about Risk for Injury.

  1. Berg-Weger, M., & Stewart, D. B. (2017). Non-Pharmacologic Interventions for Persons with Dementia. Missouri medicine, 114(2), 116–119.
  2. Budnitz DS, Salis S. Preventing medication overdoses in young children: an opportunity for harm elimination. Pediatrics 2011;127:e1597-9.
  3. Chuang YH, Huang HT. Nurses’ feelings and thoughts about using physical restraints on hospitalized older patients. J Clin Nurs. 2007 Mar;16(3):486-94.
  4. Duhn, Lenora; Godfrey, Christina; Medves, Jennifer (2020). Scoping review of patients attitudes about their role and behaviors to ensure safe care at the direct care level. Health Expectations, (), hex.13117–. doi:10.1111/hex.13117
  5. Esechie, A., Bhardwaj, A., Masel, T., & Raji, M. (2019). Neurocognitive sequela of burn injury in the elderly. Journal of clinical neuroscience, 59, 1-5.
  6. Fares A. (2018). Pharmacological and Non-pharmacological Means for Prevention of Fractures among Elderly. International journal of preventive medicine, 9, 78.
  7. Gonzalez, D., Mirabal, A. B., & McCall, J. D. (2021). Child abuse and neglect. StatPearls [Internet].
  8. Hammervold, U.E., Norvoll, R., Aas, R.W. et al. Post-incident review after restraint in mental health care -a potential for knowledge development, recovery promotion and restraint prevention. A scoping review. BMC Health Serv Res 19, 235 (2019).
  9. Johnson M, George A, Tran DT. International Journal of Nursing Practice 2011; 17: 60–66
  10. Kochitty, A., & Devi, S. (2015). A study to assess the effectiveness of a self instructional module on the knowledge &‎ practice regarding proper body mechanics among the critical care nurses in selected hospitals of Pune. J Adv‎ Sci Res, 6(4), 13-21.
  11. Lohse, K. R., Dummer, D. R., Hayes, H. A., Carson, R. J., & Marcus, R. L. (2021). Combining the AM-PAC “6-Clicks” and the Morse Fall Scale to Predict Individuals at Risk for Falls in an Inpatient Rehabilitation Hospital. Archives of Physical Medicine and Rehabilitation, 102(12), 2309-2315.
  12. Peacock, S., & Patel, S. (2008). Cultural Influences on Pain. Reviews in pain, 1(2), 6–9.
  13. Pickett, W., Dostaler, S., Craig, W., Janssen, I., Simpson, K., Shelley, S. D., & Boyce, W. F. (2006). Associations between risk behavior and injury and the protective roles of social environments: an analysis of 7235 Canadian school children. Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention, 12(2), 87–92.
  14. Sabol, T. P., & Haley, E. S. (2006). Wheelchair evaluation for the older adult. Clinics in geriatric medicine, 22(2), 355-375.
  15. Sasor, S. E., & Chung, K. C. (2019). Upper Extremity Burns in the Developing World: A Neglected Epidemic. Hand clinics, 35(4), 457–466.
  16. Thom, R., Hogan, C., & Hazen, E. (2020). Suicide risk screening in the hospital setting: a review of brief validated tools. Psychosomatics, 61(1), 1-7.
  17. Walters, D. (2017). Enclosure bed: A tool for calming agitated patients. American Nurse Today, 12(9), 25+.
  18. Kim Davis, M. S. P. T., Kreutz, D., & Sprigle, S. H. (2008). Seating and Positioning. Spinal Cord Injuries-E-Book: Management and Rehabilitation, 90, 254
  19. Longridge, E. (2013). How to identify same‐name patients to improve safety. Prescriber, 24(18), 13-16.
  20. Whiteside, M. M., Wallhagen, M. I., & Pettengill, E. (2006). Sensory impairment in older adults: Part 2: Vision loss. AJN The American Journal of Nursing, 106(11), 52-61
  21. Snyder, S. R., Favoretto, A. M., Derzon, J. H., Christenson, R. H., Kahn, S. E., Shaw, C. S., … & Liebow, E. B. (2012). Effectiveness of barcoding for reducing patient specimen and laboratory testing identification errors: a Laboratory Medicine Best Practices systematic review and meta-analysis. Clinical biochemistry, 45(13-14), 988-998
  22. Beyea, Suzanne C. “Patient identification–a crucial aspect of patient safety.” AORN Journal, vol. 78, no. 3, Sept. 2003, pp. 478+. Gale Academic OneFile
  23. Saufl, N. M. (2009). 2009 National patient safety goals. Journal of PeriAnesthesia Nursing, 24(2), 114-118.
  24. Barnsteiner JH. Medication Reconciliation. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 38.
  25. Bergman R, De Jesus O. Patient Care Transfer Techniques. [Updated 2021 Oct 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
  26. Davis KL, Davis DD. Home Safety Techniques. [Updated 2021 Jul 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
  27. Camins, B. C., & Fraser, V. J. (2005). Reducing the risk of health care–associated infections by complying with CDC hand hygiene guidelines. The Joint Commission Journal on Quality and Patient Safety, 31(3), 173-179.
Gil Wayne ignites the minds of future nurses through his work as a part-time nurse instructor, writer, and contributor for Nurseslabs, striving to inspire the next generation to reach their full potential and elevate the nursing profession.

Leave a Comment

Share to...