HELP with nursing diagnosis interventions!!

[peaceloveheal]

Hey everyone, I had my first clinical yesterday and am so lost on my paperwork. We have Problem List Flowsheets instead of care plans for right now. My teacher assigned me the problem "risk for injury" for my CVA with hemiplegia patient. I'm suppose to come up with at least 2 interventions and am having the hardest time. I looked in my Ackley book and everything in there says "risk for injury r/t". I was thinking about using "risk for injury r/t impaired skin integrity" but then was unsure since that wasn't the EXACT problem she assigned me. Am I suppose to pick something like that or was she not specific enough with my problem? Thank you so much in advance! I'm 3 seconds away from a nervous breakdown trying to figure it out.

[Nurse Kyles, BSN, RN]

Take a deep breath!

You could do risk for injury r/t sensory dysfunction.

Possible nursing interventions can be taken from the risk for injury or risk for fall diagnosis section of your Ackley book. It is hard to say appropriate interventions without meeting the client, but these might send you in the right direction:

Nursing Interventions: (Nurse will:)

suggest family stay with the client to prevent client from accidentally falling or pulling out tubes.

Complete a fall risk assessment

Maintain bed in low position

Remove all possible hazards from the room

Routinely assist with toileting

Good Luck!

[Mike R, ADN, BSN, RN]

It's easy to think too hard about these things. Think down to the basic levels. How could one keep a patient safe who is as risk of falling? In addition to what Kylee said, how about raised bed rails or teaching to ask for assistance when getting out of bed.