Nursing Diagnosis: Domain 11 Class 2 Diagnosis Code 00035 Risk for Injury related to complications of mild traumatic head

injury

Definition of Diagnosis: Susceptible to physical damage due to environmental conditions interacting with the individual's adaptive and defensive resources, which may
compromise health.
CUES/ Defining Characteristics Nursing Outcomes Classifications Nursing Interventions Classifications Evaluation
Subjective:  NOC 1: Balance NIC 1: Fall Prevention After hospital stay, Patient will be able to
020206 Dizziness achieve desired outcomes as evidenced by:
 Patient is responsive but complains  Identify cognitive or physical deficits  Decreased complaints of headaches
Outcome Rating: Maintained at 2
of headache and confusions of the patient that may increase and confusions
increased at 5
potential of falling in a particular  Patient will be able to perform fall
Objective: 1- Severe
environment techniques to minimize injury
2- Substantial
 Swelling on temporal area with a 3  Place articles within easy reach of the
3- Moderate
cm laceration patient
4- Mild
 Ears & Nose are unremarkable 5- None  Instruct patient to call for assistance
with movement, as appropriate
 NOC 2: Physical Injury Severity
191303 Lacerations  Teach patient how to fall as to
Outcome Rating: Maintained at 2 minimize injury
increased at 5  Use side rails of appropriate length and
1- Severe height to prevent falls from bed, as
2- Substantial needed
3- Moderate NIC 2: Surveillance
4- Mild  Establish the frequency of data
5- None collection and interpretation, as
Closed Head Injuries indicated by status of the patient
Outcome Rating: Maintained at 2  Monitor patient’s ability to do self-care
increased at 5 activities
1- Severe  Monitor neurological status
2- Substantial  Monitor vital signs, as appropriate
3- Moderate  Compare current status with previous
4- Mild status to detect improvements and
5- None deterioration in patient’s condition