Nurse's Pocket Guide

isk for TRAUMA
musculoskeletal function, awareness of own safety needs,
and general well-being.
• Provide quiet environment and reduced stimulation, as indicated.
Helps limit confusion or overstimulation for clients
at risk for such conditions as seizures, tetany, autonomic
hyperreflexia.
• Refer to counseling/psychotherapy, as need indicates, especially
when individual is “accident-prone”/self-destructive
behavior is noted. (Refer to NDs risk for other-directed/
self-directed Violence.)
NURSING PRIORITY NO.4.To promote wellness (Teaching/Discharge
Considerations):
• Review client’s therapeutic regimen on a continual basis when
under direct care (e.g., client’s vital signs, medications, treatment
modalaties, infusions, nutrition, physical environment)
to prevent healthcare-related complications
• Stress importance of obtaining assistance when weak and
when problems of balance, coordination, or postural
hypotension are present to reduce risk of syncope/falls.
• Encourage use of warm-up/stretching exercises before engaging
in athletic activity to prevent muscle injuries.
• Recommend use of seat belts; fitted helmets for cyclists,
skate/snowboarders, skiers; approved infant seat; avoidance of
hitchhiking; substance abuse programs to promote transportation
safety.
• Refer to accident prevention programs (e.g., medication/drug
safety; mobility/transfer device training; driving instruction;
parenting classes, firearms safety, workplace erogomics, etc.).
• Develop fire safety program (e.g., family fire drills; use of
smoke detectors; yearly chimney cleaning; purchase of fireretardant
clothing, especially children’s nightwear; safe use of
in-home oxygen; fireworks safety).
• Problem solve with client/parent to provide adequate child
supervision after school, during working hours, on school
holidays; or day program for frail/confused elder.
• Discuss necessary environmental changes (e.g., decals on glass
doors to show when they are closed, lowering temperature on
hot water heater, adequate lighting of stairways; tamper-proof
medication containers, safe chemical/poisons storage) to prevent/reduce
risk of accidents.
• Identify community resources (e.g., financial to assist with
necessary corrections/improvements/purchases).
• Recommend involvement in community self-help programs,
such as Neighborhood Watch, Helping Hand.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
720 Cultural Collaborative Community/Home Care