Friday, January 20, 2012

Nursing Interventions for Risk for Injury

Risk for Injury

NANDA Definition:

The risk of injury as a result of the interaction of environmental conditions with individual adaptive response and defense sources.

Related To :
[Substance intoxication]
[Substance withdrawal]
[Disorientation]
[Seizures]
[Hallucinations]
[Psychomotor agitation]
[Unstable vital signs]
[Delirium]
[Flashbacks]
[Panic level of anxiety]

Goals
  • Short-Term Goal : Client’s condition will stabilize within 72 hours.
  • Long-Term Goal : Client will not experience physical injury.

Nursing Intervention for Risk for Injury

  1. Maintain a closed central IV system using Luer-Lok connections and taping of all connections. Rationale: Inadvertent disconnection of central IV system can result in lethal air emboli.
  2. Administer appropriate TPN solution via peripheral or central venous route, including peripherally inserted central catheter (PICC) lines and tunneled catheters. Rationale: Solutions containing high concentrations of dextrose more than 10% must be delivered via a central vein because they result in chemical phlebitis when delivered through small peripheral veins.
  3. Monitor for potential drug and nutrient interactions. Rationale: Various interactions are possible, such as digoxin in conjunction with diuretic therapy, which can cause hypomagnesemia; hypokalemia may result from chronic use of laxatives, mineralocorticoid steroids, diuretics, or amphotericin.
  4. Assess catheter for signs of displacement out of central venous position: extended length of catheter on skin surface, leaking of IV solution onto dressing, client complaints of neck arm pain, tenderness at catheter site, or swelling of extremity on side of catheter insertion. Rationale: Central venous catheter tip may slip out of superior vena cava and migrate into smaller innominate and jugular veins, causing a chemical thrombophlebitis. Incidence of subclavian or superior vena cava thrombosis is increased with extended use of central venous catheters.
  5. Inspect peripheral TPN catheter site routinely and change sites at least every other day or per protocol. Rationale: Peripheral TPN solutions, although less hyperosmolar, can still irritate small veins and cause phlebitis. Peripheral venous access is often limited in malnourished clients, but site should still be changed if signs of irritation develop.
  6. Investigate reports of severe chest pain or coughing in clients with central line. Turn client to left side in Trendelenburg position, if indicated, and notify physician. Rationale: Suggests presence of air embolus requiring immediate intervention to displace air into apex of heart away from the pulmonary artery.
  7. Maintain an occlusive dressing on catheter insertion sites for 24 hours after subclavian catheter is removed. Rationale: Extended catheter use may result in development of catheter skin tract. Once the catheter is removed, air embolus is still a potential risk until skin tract has sealed.

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