Risk for physical trauma

Domain 11. Safety-protection
Class 2. Physical injury
Diagnostic Code: 00038
Nanda label: Risk for physical trauma
Diagnostic focus: Physical trauma

Nursing diagnosis is a key component of the nursing process which diagnoses, creates interventions, and plans follow-up to address a patient’s condition. It is important for nurses to be able to accurately diagnose and assess the risk for physical trauma in order to effectively treat patients. A nurse must be able to identify warning signs of potential physical trauma and take preventative measures to minimize or avoid these risks. The Diagnosis of Risk for Physical Trauma deals with the application of nursing assessment and therapeutic knowledge to aid in the management and treatment of individuals, families, and communities. Nurses may review medical history, conduct detailed assessments of the body systems, analyze physical evidence, or refer patients to appropriate health care specialists or services in order to detect and prevent physical traumas.

NANDA Nursing Diagnosis Definition

Risk for Physical Trauma is defined by the NANDA nursing organization as “At risk of harm, assault, or injury to body parts caused by environmental factors and internal mechanisms.” This can include falls, drowning, chemical/radiation exposure, and other environmental hazards that may cause physical injuries ranging from minor cuts and bruises to life-threatening conditions. The nurse must assess the individual’s current physical state, as well as the surrounding environment and any predisposing factors, in order to identify those at risk and take the necessary steps to prevent physical trauma.

Risk Factors

There are several risk factors that can increase an individual’s chance of experiencing physical trauma. These factors can vary from demographics to environmental hazards, and may include any of the following:

• Age: Elderly people are more at risk of physical traumas due to reduced mobility and deteriorating physical health.
• Sex: Women are usually more exposed to certain types of physical trauma than men.
• Body size: Individuals who are shorter or weigh less are likely to experience greater physical trauma.
• Medical Conditions: Certain medical conditions such as Parkinson’s and multiple sclerosis can cause physical instability and lead to an increased risk for physical trauma.
• Environmental hazards: Physical environments full of obstacles or without proper safety protocols increase the risk for falls, burns, or other traumas.

At Risk Population

The individuals most likely to be at risk of physical trauma may include:

• Children: Young children, due to their lack of development, are more vulnerable to a variety of risks.
• Elderly: Older individuals often experience decreased mobility, diminished response time, and weakened vision which increases the risk of physical injury.
• Patients with mobility issues: For example, wheelchair-bound individuals are more likely to experience falls or physical trauma due to their impairment.

Associated Conditions

Physical trauma can lead to a variety of medical issues, including some long-term complications. Depending on the extent of injury and the health of the individual, potential complications of physical trauma may include:

• Infection: Wounds or injuries may become infected if not properly treated, leading to further medical problems.
• Fractures: Bones may break or crack due to physical trauma, resulting in intense pain and long-term effects.
• Hypothermia: If a person experiences prolonged exposure to cold temperatures, hypothermia can occur.
• Brain/Spinal Injury: Serious physical traumas can leave lasting damage to the brain or spinal cord, resulting in paralysis or even death.

Suggestions of Use

Nurses can make use of the Diagnosis of Risk for Physical Trauma to develop prevention strategies for their patients. It is important for nurses to be able to recognize at-risk individuals and adjust their care accordingly. Nursing diagnostic assessments enable nurses to evaluate a patient’s current physical state and assess the environmental factors that can increase the risk of physical trauma. Through the diagnosis, nurses can provide recommendations and establish preventative measures to reduce the risk of physical trauma.

Suggested Alternative NANDA Nursing Diagnosis

If a different diagnosis is more appropriate for the patient, it may be helpful to consider alternative NANDA Nursing Diagnosis such as:

• Imbalanced Nutrition: Less Than Body Requirements
• Ineffective Health Maintenance: Risk for Disease Process
• Risk for Impaired Skin Integrity: Blister Formation
• Risk for Deficient Fluid Volume: Excessive Hemolysis
• Risk for Ineffective Airway Clearance: Hyperkalemia

Usage Tips

When making use of the Diagnosis of Risk for Physical Trauma, nurses should consider the following tips to ensure the accuracy of the diagnosis:

• Complete an accurate physical examination: Before making any decisions, nurses should conduct a thorough physical exam to identify any underlying risks of physical trauma.
• Be aware of environmental factors: The environment can pose certain risks, such as slippery floors, steep staircases, or hazardous surfaces. Nurses should adjust the plan of care to account for these risks.
• Provide adequate safety training: Nurses should make sure the patient or the patient’s family is aware of the potential dangers and have the knowledge and skill to mitigate them, such as calling for help in case there is an accident.
• Evaluate patient history: Nurses need to have a thorough understanding of the patient’s medical history to properly assess any potential risks involved in their care.
• Make use of preventative measures: Taking proactive steps can help mitigate some of the physical trauma risks associated with certain environments, conditions, and activities.

NOC Outcomes

When diagnosing Risk for Physical Trauma and creating a plan of care, nurses may consider the following NOC Outcomes:

• Mobility: Ability to move freely and independently.
• Adequate Nutrition: Obtaining and digesting necessary nutrients to support health.
• Comfort Level: Level of comfort and ease of both physical and emotional aspects.
• Body Temperature Regulation:Ability to maintain normal body temperature and avoid hyperthermia or hypothermia.
• Self Care: Ability to meet basic daily needs and live independently.

Evaluation Objectives and Criteria

To accurately assess the patient’s risk for Physical Trauma, nurses should strive to meet objectives including:

• Establishing a baseline level of physical activity: The nurse should work with the patient to evaluate their current physical fitness and range of motion to identify areas of improvement or risk.
• Recognizing behavioral patterns: The nurse should regularly check the patient’s behavior to identify changes in activity that could indicate a risk of physical trauma.
• Preventative education: The nurse should provide the patient with adequate information about risky behaviors and how to mitigate them.
• Assess environmental hazards: The nurse should continually assess the physical environment for any potential risks that could lead to physical trauma.

NIC Interventions

Nurses may employ the following NIC Interventions to prevent physical trauma:

• Fall Prevention: Implementing protective measures, such as floor mats, grab bars, and handrails, to reduce the risk of falls.
• Proper Positioning: Positioning the patient in comfortable and safe positions to reduce the risk of developing pressure sores.
• Task Assistance: Assisting the patient when performing tasks to prevent slips or missteps.
• Assistance with Mobility: Providing support or devices when needed to maintain balance and stability.
• Orientation Assessment: Creating a detailed assessment of the patient’s orientation to the environment to identify risks.

Nursing Activities

Nurses must perform certain activities to identify, prevent, and treat physical trauma. These activities may include:

• Assessing the patient: Assessing the patient’s past medical history as well as current vitals and physical state.
• Performing physical examinations: Examining any wounds or bruises to determine the extent of the trauma and best course of action.
• Evaluating environmental hazards: Analyzing the environment, such as stairs, floor surfaces, etc., to check for potential issues.
• Creating safety plans: Developing and implementing safety plans, such as wearing helmets or using protective gear.
• Educating patients: Instructing the patient on how to prevent risks and manage physical trauma.

Conclusion

It is important for nurses to be able to identify and intervene in cases of physical trauma. By performing a thorough assessment, nurses can better recognize those at risk and provide the appropriate interventions to reduce or prevent the risk. Nurses must be aware of relevant NANDA Nursing Diagnosis and associated conditions, as well as proper usage tips and evaluation objectives and criteria, to ensure the safety and well-being of their patients.

FAQs

• What is Risk for Physical Trauma? Risk for Physical Trauma is a nursing diagnosis which focuses on assessing the risk of harm to an individual’s body due to environmental factors and internal mechanisms.
• Who is at risk of physical trauma? Children, elderly individuals, and those with mobility issues are at an increased risk of suffering physical trauma.
• What are NOC outcomes for Risk for Physical Trauma? NOC outcomes for Risk for Physical Trauma include Mobility, Adequate Nutrition, Comfort Level, Body Temperature Regulation, and Self Care.
• What types of interventions may be used to prevent physical trauma? Interventions for preventing physical trauma may include Fall Prevention, Proper Positioning, Task Assistance, Assistance with Mobility, and Orientation Assessment.
• What activities should a nurse perform in cases of physical trauma? Activities related to physical trauma include Assessing the patient, performing physical examinations, evaluating environmental hazards, creating safety plans, and educating patients.