Unfortunately, injuries happen in healthcare and can take on many different forms. It is vital the nurse is aware of potential injuries, assesses for risks, implements the necessary actions to minimize risks, and knows how to care for a patient should an injury occur. An injury is considered any type of damage to one’s body. A comprehensive list of potential injuries a nurse may encounter with a patient would be quite extensive however, some examples of potential injuries include:
- Sprains or strains
- Burns or bruises
- Skin tears or cuts
- Pressure ulcers
- Self-inflicted injuries
Risk Factors for Injury
- Impaired mobility
- Impaired sensory
- Abnormal blood profile
- Mental health illness
Expected Patient Outcomes
- Patient will remain free from falls
- Patient will remain free from any form of self-harm
- Patient will remain free from any skin breakdown or impairment in skin integrity
Nursing Assessment for Risk for Injury
1. Assess patient’s general status
This will allow the nurse to gauge the patient’s present condition and the likelihood that an injury could occur.
2. Assess patient’s current mobility level.
Understanding the patient’s current level of mobility is imperative to providing a safe environment for the patient. This allows the nurse to identify if additional mobility equipment (i.e. walker, cane) is necessary for the patient.
3. Assess patient’s understanding of one self’s activity level and mobility restrictions.
This allows the nurse to understand if the patient perceives himself or herself at risk of potential injury, and if the patient has an appropriate understanding of his or her current level of activity.
4. Assess patient’s environment.
Assessing the environment will assist the nurse in identifying potential risk factors for injury.
5. Complete a throughout head-to-toe assessment.
A head-to-toe assessment will allow the nurse to gather a complete picture of the patient and his/her medical condition and what within that could put the patient at risk of injury
6. Review patient’s chart thoroughly including all vital signs and lab work.
This allows the nurse to identify additional potential risk factors (i.e. malnutrition, abnormal lab values, abnormal vital signs)
7. Utilize appropriate screening tools (i.e. Morse Fall Scale, Braden Scale).
These tools further assist the nurse with assessing an individual patient’s risk factors for specific types of injuries such as falls or skin breakdown.
Nursing Interventions for Risk for Injury
1. Monitor vital signs.
Abnormal vital signs could put the patient at risk of falls resulting in injury due to low blood pressure.
2. Monitor mental status.
Altered mental status could increase a patient’s risk of injury as the patient may not be fully aware of their surroundings and what is considered safe
3. Implement fall precautions as appropriate.
Patients at an increased risk of falling are also at an increased risk of injury. By identifying patients that are at an increased risk of falls the nurse can implement measures to prevent falls from occurring initially. Measures the nurse can take include utilizing bed and chair alarms, putting fall mats on the floor beside the bed, and applying signage to the patient’s door indicating the risk of falls.
4. Assist patient with frequent position changes.
Patients with impaired mobility may be at an increased risk of skin breakdown and skin injury. Assisting with frequent position changes will decrease the potential risk of skin injuries.
5. Provide safe environment (i.e. remove tripping hazards such as rugs or anything on the floor, remove any cords from rooms of individuals displaying suicidal ideation, ensure patient’s belongings are within appropriate reaching distance).
Providing a safe environment for patients will decrease the risk of potential injuries. Safe environments should be personalized to each individual patient and their individual risk factors based off of the nursing assessment.
6. Complete purposely hourly rounding and ensuring the call-light is within reach.
This allows the nurse to check on the patient frequently and assist the patient in getting anything that is needed thereby reducing potential risk of injury.
7. Educate patient.
Tailor patient education to each individual patient and what measures the patient can take while hospitalized and once discharged home to prevent accidents or injuries from occurring.
Prevention is key to reducing the risk of injury for patients. The nurse must be aware of this and be vigilant in conducting the proper nursing assessments to identify risk factors and then take time to develop a care plan that will minimize these risks.
References and Sources
- Ackley, B.J., Ladwig, G.B., Flynn Makic M.B., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing diagnosis handbook: An evidence-based guide to planning care (12th edition). Mosby.
- Medline Plus. (September 2021). Wounds and injuries. https://medlineplus.gov/woundsandinjuries.html
- Nanda. (2020). Nanda nursing diagnosis list. http://www.nandanursingdiagnosislist.org/functional-health-patterns/high-risk-of-injury/