Risk For Injury

 

Date/  Cues

Need

Time J U L Y

,

1 1

Goal of Care

Diagnosis

-

Nursing

Risk for injury r/t right sided body

After 2 hrs of nursing intervention, the

right sided

A

weakness

patient will be able to

assessment

body

L

secondary to

identify and apply

regarding

weakness

T

CVA

methods to promote

safety issues

safety such as:

when

H

A cerebrovascular

E

accident, also known

R

as a CVA or stroke, is a blood clot or

1.) Perform thorough

July , 2011 @ 9pm 7-3 shift

Goal Met

planning for

After 2 hours of

client care

nursing care, patient

excessive

and/or

was able to identify

activities

preparing for

and apply methods

discharge

to promote safety.

Rationale: P

Evaluation

Intervention

H E

OBJECTIVE:

2 0

Nursing

a.) limiting

b.) Use of

C

ruptured artery that

E

causes damage to

assistive

from care.

@

P

some part of the

devices such

 ®Failure to

a.) Patient was

7 am

T I

as: wheel chair

accurately assess and

able to limit activities

brain by interrupting blood flow and oxygen. The area of

O

the brain damaged

intervene or

N

dictates what kind of

refer these

wheel chair in

disability will result

issues can

transferring

and whether the

place the

from one

client at

place to

-

condition is

b.) Able to used

 

H

temporary or

needless risk

E

permanent. Even if

and creates

A

someone is still able

negligence

L

to walk and maintain mobility after a

issues for

T

stroke, home

the

H

modifications may be

healthcare

necessary to prevent

practitioner.

M

falls and injuries. Factors that

2.) Ascertain

A

increased the risk for

knowledge

N A

injury include decrease LOC.

of safety needs/injury

G

Weakness, f laccidity laccidity,,

prevention

E

spasticity, altered thought process,

and

M

motor, visual, and

motivation

E

spatial perceptual

 ® to prevent

N

impairments. ( Black

injury in

T

& Hawk: 2005:2128)  

home, community,

P

and work

A

setting.

T

3.) Assess

T

mood,

another.

 

E

coping

R

abilities,

N

personality styles (e.g., temperament , aggression, impulsive behaviour, level of selfesteem)  ® That may result in carelessness  /increase risk-taking without consideratio n of consequenc es. 4.) Provide healthcare

 

within a culture of safety (e.g., adherence to nursing standards of care and facility safecare policies)  ® to prevent errors resulting in client injury, promote client safety, and model safety behaviours for client/SO(s): Maintain bed/chair in

 

lowest position with wheels locked Ensure that pathway to bathroom is unobstructed and properly lighted. Place assistive devices (e.g., walker, cane, glasses, hearing aid) within reach. Instruct client/SO(s) to request assistance as needed; make sure call light is within reach and client knows how to

 

operate. Monitor environment for potentially unsafe conditions and modify as needed. 5.) Demonstrate  / encourage use of techniques to reduce  /manage stress and vent emotions, such as anger, hostility. 6.) Discuss importance of selfmonitoring of conditions/ 

 

emotions  ® that can contribute to occurrence of injury (e.g., fatigue, anger, irritability)