Safety Nursing Diagnosis & Care Plan

Accidents and injuries are the leading causes of death among young men, while suffocation is the most common cause of death among infants. Drowning deaths are most common in toddlers. Additional causes of unintentional injuries include motor vehicle accidents, poisoning, drug overdoses, burns, and falls.

The following are the risk factors that increase the patient’s risk for injury:

Individual factors:

  • Neuromuscular impairments that may cause decreased muscle strength and alteration in gait and balance
  • Extremes in age (very young or very old)
  • Perceptual disturbances
  • Chronic debilitating illnesses
  • Nonadherence with safety protocols
  • Recent physical trauma
  • Low socioeconomic status
  • Smoking, alcohol, or drug abuse
  • Lifestyle choices
  • Language barriers
  • Developmental barriers
  • Impaired senses (hearing, vision)
  • Complex therapeutic regimens
  • Psychological illnesses or emotional grief
  • Lack of assistive support or supervision

Environmental factors:

  • Unsafe weather-related conditions
  • Cluttered environments
  • Insufficient automobile restraints
  • Insufficient lighting
  • Lack of resources or equipment
  • Occupational hazards

Laboratory testing and imaging can evaluate the impact of injuries such as fractures or internal bleeding. Safety may also be preserved by avoiding injuries, such as when performing a barium swallow study to assess swallowing to prevent aspiration.

Nursing Process

Patient safety is a priority after ensuring airway stabilization and circulation. Patients receiving inpatient care are at an increased risk for injuries due to immunocompromised states, unfamiliar settings, invasive equipment and procedures, high-risk medications, and alterations in mental status. Care planning often includes elements of safety to prevent injuries and harm while inpatient and after discharge.

Nursing Care Plans Related to Safety

Risk for Falls

Patients may be at risk for falls for any number of reasons.

Nursing Diagnosis: Risk for Falls

Related to:

  • Altered glucose levels
  • Decreased lower extremity strength and balance
  • Unsafe, cluttered environment
  • Use of assistive devices
  • Acute illnesses
  • Chronic conditions that affect mobility
  • Older age
  • Environmental hazards
  • Disorientation

As evidenced by:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred, and the goal of nursing interventions is aimed at prevention.

Expected outcomes:

  • Patient will not experience any falls.
  • Patient will demonstrate measures to prevent falls.

Assessment:

1. Assess the patient’s risk factors that increase the risk for falls.
Patients aged >65 or <2 years old, or those with chronic debilitating diseases, polypharmacy, recent trauma, on prolonged bed rest, etc., are at increased risk for falls. Fall-risk scales may be used to assess patient risk accurately.

2. Evaluate the use and misuse of assistive devices.
Assess the patient’s gait and the need for equipment. If using equipment, observe that the patient is using it correctly.

Interventions:

1. Review and monitor medication use.
Medications such as sedatives and narcotics increase drowsiness and falls if the patient is not used to their effects. Continuously monitor the effects of a new medication that could cause confusion or impairment and educate the patient on these side effects prior to discharge.

2. Monitor the environment for hazards.
Unfamiliarity increases the risk of falls. Patients receiving IV fluids may get tangled in their IV lines or trip over their pump. Other equipment in the room, such as oxygen tubing or sequential compression devices, can present a falling hazard.

3. Collaborate with PT/OT.
Patients may need instruction on exercises to increase strength, coordination, or balance. Physical/occupational therapists can recommend equipment that can benefit the patient in keeping them safe.

4. Keep the bed position low with the bed alarm on.
Patients who are identified as a high risk for falls should always have their bed kept in a low position with the bed alarm on anytime staff is not at the bedside.


Risk for Injury

The patient is vulnerable to injury from internal and external causes.

Nursing Diagnosis: Risk for Injury

Related to:

  • Altered cerebral function
  • Impaired mobility
  • Loss of limbs
  • Impaired vision
  • Hearing impairment
  • Malnutrition
  • Psychosis
  • Medication side effects
  • Chemicals
  • Immunosuppression

As evidenced by:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred, and the goal of nursing interventions is aimed at prevention.

Expected outcomes:

  • Patient will identify factors that increase the risk of injury.
  • Patient will utilize safety measures to prevent injury.
  • Patient will remain free of injury.

Assessment:

1. Assess physical and emotional factors affecting safety.
Patients may be at an increased risk for injury due to disturbed thought processes, grief, lack of sleep, recent trauma, major health changes, and more that can affect their decision-making abilities.

2. Note socioeconomic factors.
A lack of housing, transportation, or access to resources increases the potential of injuries from improper self-care and medical support.

3. Assess for abuse.
The nurse is a mandated reporter of abuse. The nurse can assess for bruises in different stages of healing, frequent fractures, or question patients about emotional or verbal abuse.

Interventions:

1. Refer to resources as necessary.
Prevent injuries by ensuring vulnerable patients are receiving competent care. Children, adults with developmental delays, and older adults with dementia may need in-home care or daycare services.

2. Administer medications using the “5 rights”.
Nurses are less likely to make mistakes when double-checking medications for the right patient, medication, dose, route, and time. If medication scanners are available, they should be used and not bypassed.

3. Teach patients and families about basic safety measures.
Injury prevention requires the family’s awareness and adherence (i.e., only using medical equipment as advised, wearing seatbelts, and keeping cleaning products and medications locked away).

4. Instruct family on first-aid strategies.
Even with prevention, accidents and injuries occur. Teaching families about first aid strategies facilitates swift interventions and prevents further complications.


Risk for Aspiration

Some patients may be at risk of inhaling substances into the tracheobronchial passages.

Nursing Diagnosis: Risk for Aspiration

Related to:

  • Reduced level of consciousness
  • Depressed cough/gag reflexes
  • Impaired swallowing
  • Impaired protective reflexes
  • Oral/facial surgery or trauma
  • Stroke/paralysis
  • Presence of tracheostomy
  • Tube feedings

As evidenced by:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred, and the goal of nursing interventions is aimed at prevention.

Expected outcomes:

  • Patient will maintain a clear airway.
  • Patient will not experience aspiration episodes as evidenced by the following indicators:
    • Absence of coughing after swallowing
    • Absence of hoarseness
    • No pocketing of food
    • No changes in respiratory status or lung sounds
    • No alterations in LOC

Assessment:

1. Confirm placement of enteral tube feedings.
Tube placement may be evaluated through an x-ray, pH test, or auscultation at the bedside. Patients who are intubated, with a decreased level of consciousness or neurological impairment, are at increased risk of aspiration.

2. Monitor gag reflex.
The gag/swallow reflex can be assessed at the bedside before offering food or liquids. Any concerns should be further assessed through a swallow study.

Interventions:

1. Keep the head elevated at 30 to 45 degrees during tube feedings.
Head elevation helps to prevent reflux due to reverse gravity. The head of the bed should be maintained at this level for an hour after feedings.

2. Monitor gastric residual volumes between or before bolus feedings.
Large gastric residuals may suggest poor digestion or an incompetent esophageal sphincter that results in aspiration. Hold feedings and contact the physician for further instructions.

3. Consider medications in other formulations.
Patients with difficulty swallowing pills, especially children, may need medications crushed or prescribed as a liquid or disintegrating tablet.

4. Suction secretions from the mouth and throat.
Suctioning secretions aids in clearing the airway. Tracheostomies often require frequent suctioning to remove mucus.

5. Instruct the family on the prevention of aspiration.
Patients who need to be fed should be monitored during mealtimes. Do not rush feedings, provide small bites, encourage chewing, and consider foods that are easier to swallow.


References

  1. Appeadu MK, Bordoni B. Falls and Fall Prevention In The Elderly. [Updated 2022 Feb 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560761/
  2. Bazakis AM, Kong EL, Deibel JP. Fatal Accidents. [Updated 2022 Sep 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482328/
  3. Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice. (14th ed.). Lippincott Williams & Wilkins.
  4. Doenges, M. E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span. (10th ed.). F.A. Davis.
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Maegan Wagner, BSN, RN, CCM

Maegan Wagner is a registered nurse with over 10 years of healthcare experience. She earned her BSN at Western Governors University. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in educating through writing for other healthcare professionals and the general public.