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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Herniated Nucleus Pulposus Nanda Nursing Interventions

Herniated Nucleus Pulposus

Intervertebral Discs are the cartilage plates that form a cushion between the vertebral bodies. Hard and fibrous material is combined in one capsule. Such as ball bearings in the middle of the disc called the nucleus pulposus. Herniated nucleus pulposus is a rupture of the nucleus pulposus.

Herniated nucleus pulposus into the vertebral bodies can be above or below it, can also directly into the vertebral canal.

Pain can occur in any part such as cervical spine, thoracic (rarely) or lumbar. Clinical manifestations depend on the location, speed of development (acute or chronic) and the effect on surrounding structures. Lower back pain is severe, chronic and recurring (relapse).

Intervention Nursing Care Plan for HNP Herniated Nucleus Pulposus

1. Acute pain related to nerve compression, muscle spasm

a. Assess complaints of pain, location, duration of attacks, precipitating factors / which aggravate. Set scale of 0-10
b. Maintain bed rest, semi-Fowler position to the spinal bones, hips and knees in a state of flexion, supine position
c. Use logroll (board) during a change of position
d. Auxiliary mounting brace / corset
e. Limit your activity during the acute phase according to the needs
f. Teach relaxation techniques
g. Collaboration: analgesics, traction, physiotherapy

2. Impaired physical mobility related to pain, muscle spasms, and damage neuromuskulus restrictive therapy

a. Give / aids patients to perform passive range of motion exercises and active
b. Assist patients in ambulation activity progressively
c. Provide good skin care, massage point pressure after rehap change of position. Check the state of the skin under the brace with a specific time period.
d. Note the emotional responses / behaviors in immobilizing
e. Demonstrate the use of auxiliary equipment such as a cane.
f. Collaboration: analgesic

3. Anxiety related to ineffective individual coping

a. Assess the patient's anxiety level
b. Provide accurate information
c. Give the patient the opportunity to reveal problems such as the possibility of paralysis, the effect on sexual function, changes in roles and responsibilities.
d. Review of secondary problems that may impede the desire to heal and may hinder the healing process.
e. Involve the family

4. Knowledge deficient related to the lack of information about the condition, prognosis

a. Explain the process of disease and prognosis, and restrictions on activities
b. Give information about your own body mechanics to stand, lift and use the shoes backer
c. Discuss about treatment and side effects.
d. Suggest to use the board / mat is strong, a small pillow under your neck a little flat, bed side with knees flexed, avoid the tummy.
e. Avoid the use of heaters in a long time
f. Give information about the signs that need attention such as puncture pain, loss of sensation / ability to walk.

Source : http://nursing-care-plan.blogspot.com/2011/12/nursing-care-plan-for-hnp-herniated.html

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