Nursing diagnosis: risk for Injury/Trauma
Risk factors may include
Inability to recognize or identify danger in environment, impaired judgment
Disorientation, confusion, agitation, irritability, excitability
Weakness, muscular incoordination, balancing difficulties, disturbed perception (e.g., missing chairs, steps)
Possibly evidenced by:
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Family/Caregiver(s) Will
Safe Home Environment
Recognize potential risks in the environment.
Identify and implement steps to correct or compensate for individual factors.
Physical Injury Severity
Be free of injury.
Nursing intervention with rationale:
1. Assess degree of impairment in ability and competence and presence of impulsive behavior.
Rationale: Identifies potential risks in the environment and heightens awareness of risks so caregivers are more alert to dangers. Clients demonstrating impulsive behavior are at increased risk of injury because they are less able to control their own behavior/actions.
2. Assist caregiver to identify any risks or potential hazards and visual-perceptual deficits that may be present.
Rationale: Visual-perceptual deficits increase the risk of falls.
3. Eliminate or minimize identified hazards in the environment.
Rationale: A person with cognitive impairment and perceptual disturbances is prone to accidental injury because of the inability to take responsibility for basic safety needs or to evaluate the unforeseen consequences, such as lighting a stove or cigarette and forgetting about it, mistaking plastic fruit for the real thing and eating it, or misjudging distance involving chairs and stairs. Preventive measures can contain client without constant supervision. Activities promote involvement and keep client occupied.
4. Lock outside doors as appropriate, especially in evening and night. Do not allow access to stairwell or exit. Provide supervision and activities for client who is regularly awake during the night. Recommend use of “child-proof locks”; secure such items as medications, cleaning products, poisonous substances, tools, and sharp objects. Remove stove knobs and burners.
Rationale: As the disease worsens, the client may compusively handle or fidget with objects, including locks, or put small items in mouth, which potentiates possibility of accidental injury and death.
5. Monitor behavior routinely, note timing of behavioral changes, increasing confusion, and hyperactivity. Initiate least restrictive interventions before behavior escalates.
Rationale: Early identification of negative behaviors with appropriate action can prevent need for more stringent measures. Note: Sundowner’s syndrome develops in late afternoon or early evening, requiring programmed interventions and closer monitoring at this time to redirect and protect client.
6. Distract or redirect client’s attention when behavior is agitated or dangerous, for example climbing out of bed. Place bed in low position and mattress on floor, as indicated.
Rationale: Maintains safety while avoiding a confrontation that could escalate behavior or increase risk of injury.
7. Obtain and have client wear identification jewelry, such as bracelet or necklace showing name, phone number, and diagnosis.
Rationale: Facilitates safe return of client if lost. Because of poor verbal ability and confusion, these persons may be unable to state name, address, and phone number. Client may wander, exhibit poor judgment, and be detained by police, appearing confused, irritable, or having violent outbursts.
8. Dress according to physical environment and individual need.
Rationale: The general slowing of metabolic processes results in lowered body heat. The hypothalamic gland may be affected by the disease process or by aging, causing client to feel cold. Client may have seasonal disorientation and may wander out in the cold. Note: Leading causes of death in these clients include pneumonia and accidents.
9. Monitor for medication side effects and signs of overmedication— extrapyramidal signs, orthostatic hypotension, visual disturbances, and gastrointestinal (GI) upsets.
Rationale: Client may not be able to report signs or symptoms, and drugs can easily build up to toxic levels in the elderly. Dosages or drug choice may need to be altered.
10. Administer medications as appropriate, such as risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), or ziprasidone (Geodon).
Rationale: Some antipsychotics are favored to control agitation, aggression, halluncinations, thought disturbances, and wandering because of their lessened propensity to cause anticholinergic and extrapyramidal side effects. May help moderate “sundowning” behaviors. Note: Condition may be related to deterioration of the suprachiasmatic nucleus of the hypothalamus which controls the sleep–wake cycle.