Nursing Interventions For Gamble For Injury

Risk for Injury

NANDA Definition:

The run a endangerment of injury every bit a upshot of the interaction of environmental weather amongst private adaptive reply together with defence sources.

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

Goals

• Short-Term Goal : Client’s status volition stabilize inside 72 hours.
• Long-Term Goal : Client volition non sense physical injury.

Nursing Intervention for Risk for Injury

1. Maintain a unopen key IV organisation using Luer-Lok connections together with taping of all connections. Rationale: Inadvertent disconnection of key IV organisation tin upshot inward lethal air emboli.
2. Administer appropriate TPN solution via peripheral or key venous route, including peripherally inserted key catheter (PICC) lines together with tunneled catheters. Rationale: Solutions containing high concentrations of dextrose to a greater extent than than 10% must endure delivered via a key vein because they upshot inward chemic phlebitis when delivered through minor peripheral veins.
3. Monitor for potential drug together with food interactions. Rationale: Various interactions are possible, such every bit digoxin inward conjunction amongst diuretic therapy, which tin crusade hypomagnesemia; hypokalemia may upshot from chronic purpose of laxatives, mineralocorticoid steroids, diuretics, or amphotericin.
4. Assess catheter for signs of displacement out of key venous position: extended length of catheter on peel surface, leaking of IV solution onto dressing, customer complaints of cervix arm pain, tenderness at catheter site, or swelling of extremity on side of catheter insertion. Rationale: Central venous catheter tip may sideslip out of superior vena cava together with migrate into smaller innominate together with jugular veins, causing a chemic thrombophlebitis. Incidence of subclavian or superior vena cava thrombosis is increased amongst extended purpose of key venous catheters.
5. Inspect peripheral TPN catheter site routinely together with alter sites at to the lowest degree every other twenty-four hours or per protocol. Rationale: Peripheral TPN solutions, although less hyperosmolar, tin nonetheless irritate minor veins together with crusade phlebitis. Peripheral venous access is ofttimes express inward malnourished clients, only site should nonetheless endure changed if signs of irritation develop.
6. Investigate reports of severe breast hurting or coughing inward clients amongst key line. Turn customer to left side inward Trendelenburg position, if indicated, together with notify physician. Rationale: Suggests presence of air embolus requiring immediate intervention to can air into apex of midpoint away from the pulmonary artery.
7. Maintain an occlusive dressing on catheter insertion sites for 24 hours later subclavian catheter is removed. Rationale: Extended catheter purpose may upshot inward evolution of catheter peel tract. Once the catheter is removed, air embolus is nonetheless a potential run a endangerment until peel tract has sealed.

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