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:

Environmental factors:

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.

Related to:

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:

Assessment:

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.

Related to:

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:

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.

Related to:

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: