Prevention

Environmental Strategies
• Lighting appropriate to time of day- windows with a view to outside,
curtains open during the day and minimal lighting at night may reduce
disorientation
• Provision of single room- reduces the disturbance caused by staff attending
other patients in the same room.
• Quiet environment especially at rest times- noise reduction strategies
• Provision of clock and calendar that clients can see
• Encourage family and carer involvement-includes encouraging them to visit
• Encourage family/carer to bring in client’s personal and familiar objects
• Avoid room changes if possible- frequent changes may increase
disorientation
Clinical Practice Strategies
• Encourage/assist with eating and drinking to ensure adequate intake
• Ensure that patients who usually wear hearing and visual aids are assisted to use
them
• Regulation of bowel function – avoid constipation
• Encourage and assist with regular mobilisation (ADL)
• Encourage independence in basic ADLs
• Promote relaxation and sufficient sleep- can be assisted by regular mobilization,
massage, encouraging wakefulness during the day
• Avoid psychoactive drugs- restricted use of sleeping medication
• Manage discomfort or pain
• Provide orienting information including name and role of staff members
• Avoid use of physical restraints
• Use of interpreters and other communication aids for delirium patients
Risk of injury related to impairment in
cognitive and psychomotor function
Goals: Patient will not experience injury during hospitalization.
1. Assess general condition of the patient to determine the patient’s
condition that may cause injury.
2. Assess mood coping abilities, personality style that may result in
carelessness to determine the patient’s level of cooperation.
3. Put sticker or sign for patients at risk for injury for example delirium
patient so that healthcare providers acknowledge who has the condition
for they are responsible for implementing actions to promote patient
safety.
4. Put call bell within reach and teach how to call for assistance to prevent
patient fall and causing injury.
5. Keep bed level at the lowest to prevent patient fall from bed and
cause injury.
6. Put cardiac table within reach to prevent patient getting fall.
7. Assist patient in ADL to support patient’s independence and
promote safety.
8. Provide reality orientation frequently when interacting with patient
with delirium by presenting information about time, place or
person in order to help them understand their surroundings and
situation.
9. Keep a dim light on at night as lighting an unfamiliar environment
helps increase visibility if the patient must get up at night.
10. Put patient near to nurses’ counter to observe patient or ask family
or significant others to be with the patient to prevent him or her
from accidentally falling or pulling out tubes or cannula.
11. Avoid extreme hot and cold around patients at risk for injury (e.g.
hot or cold pack) as patients with decreased cognition or sensory
deficits cannot discriminate extremes in temperature.
12. Put patients sit in a stable chair with armrests and limit use of
wheelchairs except for transportation as needed as patient may
stand up without locking the wheels.
13. Put on safety belt when patient sit out from the bed to prevent fall
and causing injury.

Evaluation: Patient is free from injury during hospitalization.