NANDA-NursingPlan Area 11 Safety/Defense

NANDA-Nursing Plan 00038 Risk for physical trauma

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.

Area 11 Safety/Defense
Category 2 Bodily injury Bodily harm or injury

00038 Risk for physical trauma


Nursing Diagnosis: Risk for physical trauma
Definition: A condition in which tissue damage (e.g., wounds, burns, bone fractures) is likely to occur due to an accidental injury, resulting in loss of health.


In 2021, the definition has been changed as follows.


Definition: A disabling condition of sudden onset and severity that requires immediate attention.

This diagnosis focuses on trauma, but if you are dealing with internal injuries as well as trauma, please also consider “injury risk state (old; physical injury risk state)”.

1. Indications for Nursing Diagnosis Risk for physical trauma


(1) Risk of injury due to physical factors

・ Cognitive decline: Hasegawa score of 20 points or less, MMSE score of 21 points or less
・Elderly people living alone (especially elderly people with dementia)
・History of falls
・Fall assessment score risk level II or higher (See ✩ 1 below for the fall assessment score)
・Medical conditions and stages that are likely to cause self-harm (such as the acute phase and recovery phase of depression)
・ Paralysis (motor paralysis, sensory paralysis)
・ Ataxia
・Musculoskeletal diseases
① Osteoporosis (bone fragility) resulting fracture
② Knee osteoarthritis (degeneration of articular cartilage)
③ Rheumatoid arthritis (arthritis)
④ Lumbar spinal stenosis and cervical spondylotic myelopathy (degeneration of the spine)
・ Diseases with fractures and joint deformation
・ Uses restraint bands
・ Malnutrition
・ Visual impairment


(2) Improper environment

・Nurse call does not arrive
・There are no fences (stairs, windows, verandas)
・ Regional characteristics (regions with high crime rates)
・ Indoor dangers: gas leaks, octopus foot wiring
・Smoking or using fire while inhaling oxygen
・Non-slip bathroom
・ Do not wear a seat belt or a child seat when using a car
・Use of unstable chairs


(3) Risks associated with habits and work

・ Regularly use tools and heavy machinery that can be used as weapons (chainsaws, kitchen knives, anchors, hammers, heavy machinery, etc.)
・Has habits that pose a risk of burns, such as taking very hot baths or using hot water bottles
・ Driving a car or heavy machinery with residual alcohol due to alcohol poisoning or dependence

✩ 1 Fall assessment score sheet

In Japan, there is a tool for predicting falls called the Fall Assessment Score Sheet.
Depending on where you live, there are various scales such as “Downton Fall Risk” and “Morse Fall Scale”, so please do your own research.
Introducing Japan’s “Tumble Fall Assessment Score Sheet”.
The risk is classified into I to III depending on the score. Level II or higher indicates a high fall risk.


Risk level I: 1 to 9 points (possibility of falling
Risk II: 10 to 19 points (easily to fall)
Risk III: Frequent falls
Because the patient’s condition changes, it is necessary to evaluate the patient periodically from the time of admission.

2. aim setting


Goal setting by linkage (listed in the second half of the NOC)
* “Linkage” has the role of connecting “NANDA”, “NIC” and “NOC” (link means “connection”).


1) Linkage achievements


・Severity of physical injury (1913)
(Definition: signs and severity of physical injury)
・Frequency of falls (1912)
(Definition: number of times an individual fell/tumbled)
・ Fall prevention behavior (1909)
(Definition: Personal and family caregiver behavior that reduces environmental risk factors that contribute to falls)
・Knowledge: fall prevention (1828)
(Definition: degree of understanding regarding fall prevention)
Abortion behavior of alcohol abuse (1629)
(Definition: An individual’s behavior to withdraw from health-threatening alcohol consumption)
・Effects of substance addiction (1407)
(Definition: severity of changes in health status and social functioning associated with substance (drug, tobacco, alcohol) dependence)
・Safe Home Environment (1910)
(Definition: Arranging the physical environment to minimize environmental factors that may cause physical disability in the home)
・Delirium level (0916)
(Definition: severity of short-term, reversible impairment of consciousness and cognition)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do XX”,
For example, “The patient will be able to do ○○.”

・Be able to describe how to improve the environment to prevent injuries and burns.

・Environment to prevent injuries and burns can be maintained.

・Able to actively manage by yourself (does not depend on).

• Allows caregivers/carers to describe abuse.

*Nurse goals include:

・Provide life support according to the healing and recovery status of the disease, and help the normal healing process.

・Perseverely encourage the withdrawal from addiction and get involved so that the person and family can work positively.

・Remove risk factors related to falls and prevent falls.

・Efforts will be made to detect abuse at an early stage, prevent recurrence, and provide support for fundamental improvement.

・Provide physical and mental care for abused children.

・Provide assistance (improvement of the environment, change of consciousness) to remove risk factors for injuries and burns.

3. nursing plan

1) Observation plan 《OP》 *Observe the range, amount, and degree for each of the following

・ Decreased level of consciousness, abnormal vital signs (low blood pressure, tachycardia, abnormal respiratory rate, etc.)
・Scratches, bruises, wounds
・Burns
・Sprains of extremities
・Lumbar sprain
・Fractures of the extremities
・Pelvic fracture
・Femur fracture
・Vertebral fracture
・Skull fracture
・Facial fracture
・Tooth fracture
・Open head injury
・Closed head injury
・impairment of mobility
・Cognitive impairment
・Liver contusion
Rupture of the spleen
·bleeding
・Abdominal trauma
・Number of falls
・Details of the fall (when, where, what you are doing, how)
・(Persons who need to walk with an escort) Have you requested an escort by nurse call?
・ Fall risk assessment score of II or higher
・Whether the environment is designed to prevent falls ・Installation of fences ・Installation of handrails
・Adjustment of footwear (those with heels)
・Use of assistive devices (cane, walker, silver car)
・Use of glasses
・Progress of rehabilitation
・Environment in a slippery place ・Whether a non-slip mat has been pulled ・Whether it is left wet
・The illuminance of the room
・Clutter in the room
・Unfixed rugs
・Oral medicine
・Alcohol intake (how much you drink habitually)
・ Diagnosis of alcoholism (Wikipedia reference alcoholism – Wikipedia)
・Accidents and injuries due to alcohol intake, DV history
・Whether or not you have participated in the Association for Alcohol Dependence Relief (AA), and the status of your continued participation
・Persistent decline in physical activity
・Chronic motor dysfunction (cannot avoid danger)
・Chronic fatigue
– Missing school or work
・Difficult to continue working
・I am restless (disturbance of consciousness)
・Irritable
・Violent acts
・Injection marks
・Abnormal pupil
・Traffic accident history
・ Arrest history
・History of emergency outpatient visits due to poisoning
〈Safe (home) environment〉
・No fences (stairs, windows, balconies)
・Regional characteristics (regions with high crime rates)
・Indoor dangers: gas leaks, octopus foot wiring, safe management of chemicals,
・Operational status of smoke detectors
・Smoking or using fire while inhaling oxygen
・Management of dangerous goods (knives, guns (for hunting), chainsaws, etc.)
・Fire management
〈Delirium level〉
Disorientation of time, place and person
・Cognitive impairment (Hasegawa score of 20 or less, MMSE score of 21 or less)
・Expression of meaningless words
・Changes in level of consciousness ・Agitation ・Agitation ・Hallucinations ・Delusions
・Wandering
・Using tools and heavy machinery that can be used as weapons (chainsaws, kitchen knives, anchors, hammers, heavy machinery, etc.)
The habit of taking very hot baths
・The habit of using a hot water bottle
・Alcohol dependence: Driving a car or heavy machinery with residual alcohol
・Medical conditions and disease stages that are prone to self-harm (depressive convalescence, etc.)
Paralysis (motor paralysis, sensory paralysis)
・ Paralysis site, range, ADL
・Musculoskeletal diseases
・ Hip osteoarthritis, knee osteoarthritis, rheumatoid arthritis, etc.
・Presence or absence of pain, degree
・ Oral medicine
・Suppression
・ Suppression site, suppression time, skin condition due to suppression
・History of abuse, history of being abused
・Child’s physical condition (height, weight, bruises, cognitive, behavioral disorders)
・Are there any dangerous items (cigarettes, batteries, chemicals, lighters, etc.) within reach of children?
(The child’s mouth opens as much as the hole in the core of the toilet paper.
  Things that pass through the core of the toilet paper may be swallowed or accidentally swallowed)
・Do not wear a seat belt or a child seat when using a car

2) Action plan 《TP》

・In accordance with the progress of rehabilitation, while sharing information with rehabilitation, determine the method of assistance and implement assistance.
・Use non-slip rubber mats in bathrooms and bathtubs.
・Adjust the room to sufficient lighting.
・Improve the environment and install the nurse call at a position where it can be reached.
・Improve the environment and do not place anything that could be a stumbling block.
・When safety cannot be maintained, restraints (sensors for getting out of bed, mittens, limb/trunk restraints, four-point fences, etc.) will be implemented as necessary.
• When restraints are used, use restraints according to proper use and periodically assess their need.
・When restraining work, check whether there are any troubles due to restraint for each work shift.
・For patients with paralysis (motor paralysis, sensory paralysis), pay attention to the positioning of the affected side to prevent dislocation and blood flow obstruction.
– For patients with musculoskeletal disorders, provide ADL assistance according to the degree of progression of the disease.
・In order to prevent dangerous behavior and injury due to withdrawal symptoms from alcohol and drug dependence (addiction), conduct regular patrols and improve the environment.
・Make the recuperation environment suitable for ADL.
・If abuse is suspected, report to a doctor. (you will be notified from there)

3) Education plan 《EP》

・Explain the method and necessity of environmental improvement to family members living together with the person concerned, and work to prevent the foreign minister from doing so.
・(People who need to walk with an attendant) Ask them to ask for an attendant on the nurse call.
Introduce participation in self-help groups for alcohol, drug and gambling withdrawal (addiction).
(Refer to the website of ASK, a specified non-profit organization:
https://www.ask.or.jp/article/6502
* Recently, Internet addiction and game addiction have become a problem, and self-help groups for them are also introduced on the ASK website.
・Tell them that you can ask them without hesitation if you don’t understand something.

References

T. Heather Hardman, Shigemi Kamitsuru, Camila Takao Lopez. (July 1, 2021). NANDA-I Nursing Diagnosis – Definition and Classification 2021-2023 Original 12th Edition. Igaku Shoin Co., Ltd.
T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Yamaguchi Toru, Kitahara Mitsuo, Fukui Tsuguya. (2012). Today’s treatment guidelines.
Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008). Nursing Learning Dictionary (3rd Edition). Gakken Co., Ltd. (Gakken).

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