NANDA-NursingPlan Area 11 Safety/Defense

NANDA- nursing plan 00035 Risk for physical injury → Risk for injury

Area 11 Safety/Protection No danger, physical injury or damage to the immune system, prevention of loss, guarantee of safety and security
Category 2 Bodily injury Bodily harm or injury
bodily injury risk status


Nursing Diagnosis: Risk for Physical Injury (00035)
Definition: A condition in which an individual’s adaptive resources interact with surrounding environmental conditions, resulting in susceptibility to injury and loss of health.
↓↓↓↓↓
Nursing Diagnosis: Risk for Injury Status (00035)
Definition: The state of susceptibility to injury and loss of health due to environmental conditions interacting with an individual’s adaptability and defenses.

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.

Nursing diagnosis names and definitions have changed in the 2021 edition. “Related State” has been added to make it more specific.
*In this page, “Physical Injury Risk Conditions”, we will focus on the prevention of unforeseen accidents and abuse prevention.
* “Physical injury risk status” also includes fall risk and infection risk. Falls are dealt with in the Nursing Diagnosis “Fall Risk State”, and infection is dealt with in “Infection Risk State”, so please refer to that.
*Please consider “trauma risk status” for injuries caused by trauma.

Click here to check the “Risk for falls”.


1. Nursing plan “Risk for injury” target

・Decline in cognitive function
・ Hasegawa method (HDS-R) 19 points or less, the possibility of dementia, full score of 30 points
・ MMSE: Possibility of dementia at 21 points or less (30-27 normal, 26-22 suspected longitude dementia, 21 or less recognized
Suspected dementia) Full score of 30 points. MMSE is an international standard
・ Possibility of self-harm due to mental instability (delirium, restlessness, hallucinations, delusions, drunkenness)
・Abnormity of risk level II in fall assessment score (fall assessment score is ✩ 1)
・Altered level of consciousness due to drugs (psychotropic drugs, epileptic drugs, antihypertensive drugs, sleeping pills, antidepressants, etc.)
・Alteration of consciousness level due to drinking
·domestic violence
・Child abuse
・Elder abuse
Temporary delirium (postoperative delirium, ICU syndrome)
・Changes in the environment (moving rooms or hospitalization)
・Discomfort due to medical detention: risk of physical injury due to self-removal
・ Possibility of self-harm due to lack of self-care (not cutting nails), possession of weapons (a belt can lead to self-harm during the acute and recovery phases of depression, and during restlessness)
・States that are likely to be exposed to the source of infection: nosocomial infection, lack of vaccination, autoimmune disease, steroid use, skin breakdown, pressure ulcer, burn, thrombocytopenia
・Conditions in which trauma is difficult to notice (easily exacerbated) due to paresthesia: Diabetes, spinal cord injury
・ Risk of infection due to weakened immunity
・Possibility of falling due to syncope (risk of injury due to falling): hypoxia, cerebrovascular disease, arrhythmia, coronary artery disease, anemia
・High risk of fractures due to falls: regular use of pills, osteoporosis
・Exposure to toxic chemicals (cadmium, mercury, thioacetone, potassium cyanide, dioxin, etc.)
・Improve state due to anticancer drug treatment: leukopenia, thrombocytopenia
・Living environments that are not suitable for ADL (situations where it is easy to fall): steps, corridors without handrails, cluttered rooms, etc.
・Not vaccinated
・Infectious state

2. Goal setting by linkage (second half of NOC)

* “Linkage” has the role of connecting “NANDA”, “NIC” and “NOC” (link means “connection”).

1) Linkage achievements

・Severity of physical injury (1913)
(Definition: severity of signs and symptoms of physical injury)
・Frequency of falls (1912)
(Definition: Number of times an individual has fallen)
・Safe Home Environment (1910)
(Definition: maintenance of physical environment to minimize environmental factors that may cause physical injury at home)
・ Fall prevention behavior (1909)
(Definition: Individual and family caregiver behavior that reduces environmental risk factors that lead to falls)
・Risk Control (1902)
(Definition: individual actions to understand, prevent, eliminate or reduce modifiable health threats)
・Early detection of risks (1908)
(Definition: individual actions to reveal threats to personal health)
・Personal Safety Behavior (1911)
(Definition: individual actions to prevent unintentional bodily injury)
・Knowledge: physical safety of children (including the elderly and disabled) (1801)
(Definition: Degree of understanding regarding safety in raising children aged 1 to 17)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do ○○”,
For example, “The patient will be able to do ○○.”
・It is possible to create a safe medical treatment environment where unexpected accidents do not occur.

・(At home) Predict all kinds of accidents such as drowning, tumbling, confining in a washing machine, taking the wrong medicine, swallowing, suffocating, wandering, jumping out, etc., and can create an environment where people can live safely.

・In the event of domestic violence or abuse, you can talk to adults around you or someone you trust.

3. nursing plan

1 >> Observation plan <>

・Body inserts such as drains, balloon catheters, and drips
・Consciousness, delirium
・History of self-extraction such as infusion
・Presence or absence of suppression
・Skin troubles due to suppression
・Environment that may lead to accidental ingestion (internal medicine, button batteries, coins, cigarettes, cigarette butts, etc.)
・Refrigerators, washing machines, ovens, and dishwashers that can be opened even by children
・Bruises, wounds, bruises, fractures, burns on the body
・Dirty clothes, dirt on the body
・Delayed growth and development such as thinness and short stature
・Developmental disorders (delay in language development)
・ Unnatural parent explanation “I fell on my own and hit me”
・I have a strong attachment to food (I may not be allowed to eat)
・Environment without locking habits
・Director’s carelessness (neglect)
・Mental state of parents (postpartum depression, childcare burden such as twin triplets, insomnia, dissatisfaction with husband, single mother, etc.)
・Parents’ parental history (parents themselves have experience of being abused, etc.)
・Child seat not installed
・Not wearing a bicycle helmet
・Bathtub filled with hot water at all times
・Drug abuse
Companionship in case of substance abuse
・Relationship with family
Excessive drinking (alcoholism)
・Violent acts
・Weapon retention
・Understanding of oxygen therapy (whether fire is used near oxygen)
・Disturbance of consciousness, delirium
・Use of psychotropic drugs and sleeping pills
・Appropriate usage of gas, kitchen knives, etc.
・ Driving a car (elderly driver with suspected dementia)
・ Cognitive decline (Hasegawa score 19 points or less, MMSE score 21 points or less, suspected dementia)
・Human relationship troubles due to debt, gambling, etc. (gambling addiction)
・Psychiatric disorders with symptoms of hallucinations and delusions (fear of harming self or others)
Desperate situations (such as depression)
・Health problems
・Problems at work
・Low self-efficacy
・ Areas and places where many perverts appear (places where kidnapping and rape are likely to occur)
・ Being followed (injury from a stalker)

2 》 Action plan 《TP》

・Improve the environment to prevent the insertion of drips, drains, etc. from being pulled.
・If an elderly person touches a drip, use a bandage or the like so that it cannot be seen.
– If self-extraction is repeated, consider moving to another room or restraint.
・Attach locks to easy-to-open refrigerators and washing machines to prevent children from opening them.
・Keep internal medicines, cigarettes, coins, batteries, etc. out of reach.
・Do not place anything that could be used as a weapon within reach.
・(At home) Lock the door so that you cannot go outside without your eyes. (traffic accident prevention)
・(At home) Lock the door to prevent loitering. If you are wandering around, attach something that can identify you to your clothes (now there is a system that can identify your identity with a QR code Summary of municipalities that use QR codes to confirm identity | Dementia Net (ninchisho.net) )
・Installation of child seats
・When the bathtub is filled with hot water, keep an eye on it, and keep children and elderly people away alone.
– Report any suspected abuse.
・If the mental state of the abusive parent or caregiver is unstable, consult a doctor and refer them to a psychiatrist.
・Introduce self-help groups that have (or have had) the same worries when they are exhausted from the burden of raising children. Don’t be alone, don’t worry, don’t think about it. (In order not to be deceived by suspicious groups, first consult with the city’s welfare section.)
• Create a safe environment for the abused child if he/she is frightened.
・If you have a drug, alcohol, or gambling addiction, refer them to a self-help organization. (In order not to be deceived by suspicious groups, first consult with the city’s welfare section.)
・If the patient has disturbance of consciousness or delirium, watch over and assist him or her so that they do not harm themselves or others.
・If drug-induced delirium is suspected, report to the doctor (probably discontinue)
・If the patient has hallucinations or delusions, watch over and assist them so that they do not harm themselves or others.
・If self-efficacy is low, engage in relationships that lead to self-confidence, such as asking about successful experiences. Act as a bridge to clinical psychologists.
If you have a health problem or work problem, listen. (watching the acceptance process)
・If you are being followed by perverts or stalkers, consult with the police.

3 >> Education plan 《EP》

・Explain not to pull the insert such as a drip.
・If you have an insert and go to the toilet, bundle the power cords together and explain the procedure so that the drain will not be dirty.
・Use pamphlets to explain a safe environment for raising children. (It is written in the mother and child handbook).
・Teach children the importance of wearing a helmet, why they should not touch fire, and traffic safety rules.
・Explain the deterioration of various functions such as deterioration of vision due to aging, deterioration of motor function, and deterioration of judgment.
After that, think about whether you really need to drive with your family, and give them an opportunity to think about voluntarily surrendering their driver’s license.
・Think concretely about life after returning the driver’s license.
・Because there are many things in life, after consulting with the welfare department of the city, it is recommended that you join a self-help group so that you do not become desperate and do not carry everything on your own. (No suspicious groups or religions.)
・If you feel scared, don’t keep it to yourself, talk to someone you can trust. You can see a doctor and get a consultation.

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).

Thank you for coming this far. If you have any comments, impressions or questions, we are waiting for you from the comment section below (゚▽゚)

投稿者

florence.no.tomoshibi@gmail.com

コメント

コメントを残す

メールアドレスが公開されることはありません。 が付いている欄は必須項目です