Nursing Diagnosis and Care Plan

Risk for Suicide NANDA Definition

NANDA Definition - Risk for Suicide :

At risk for self-inflicted, life-threatening injury

Related Factors:

Behavioral

History of previous suicide attempt; impulsiveness; buying a gun; stockpiling medicines; making or changing a will; giving away possessions; sudden euphoric recovery from major depression; marked changes in behavior, attitude, school performance

Verbal

Threats of killing oneself; states desire to die/end it all

Situational

Living alone; retired; relocation, institutionalization; economic instability; loss of autonomy/independence; presence of gun in home; adolescents living in nontraditional settings (e.g., juvenile detention center, prison, half-way house, group home)

Psychological

Family history of suicide; alcohol and substance use/abuse; psychiatric illness/disorder (e.g., depression, schizophrenia, bipolar disorder); abuse in childhood; guilt; gay or lesbian youth

Demographic

Age: elderly, young adult males, adolescents; race: Caucasian, Native American; gender: male divorced, widowed

Physical

Physical illness; terminal illness; chronic pain

Social

Loss of important relationship; disrupted family life; grief, bereavement; poor support systems; loneliness; hopelessness; helplessness; social isolation; legal or disciplinary problem; cluster suicides

Risk for Injury related to Alzheimer's Disease

Nursing Diagnosis for Alzheimer's Disease - Risk for Injury

Nursing Care Plan : Risk for Injury related to Alzheimer's Disease

Risk for Injury Definition: At risk of injury as a result of the interaction of environmental conditions interacting with the individual's adaptive and defensive resources
NOTE: This nursing diagnosis overlaps with other diagnoses such as Risk for Falls, Risk for Trauma, Risk for Poisoning, Risk for Suffocation, Risk for Aspiration and, if the client is at risk of bleeding, Ineffective Protection. See care plans for these diagnoses if appropriate.

Alzheimer's disease is the most common form of dementia. There is no cure for the disease, which worsens as it progresses, and eventually leads to death.

Signs and symptoms of Alzheimer’s disease

Alzheimer’s disease is a progressive condition, which means that it will continue to get worse as it develops. Early symptoms include:
  • minor memory problems
  • difficulty saying the right words
These symptoms change as Alzheimer’s disease develops, and it may lead to:

  • disorientation
  • personality changes
  • behavioural changes
The exact cause for this is unknown. However, there are a number of things thought to increase the risk of developing the condition, including:
  • increasing age
  • a family history of the condition
  • previous severe head injuries
  • lifestyle factors and conditions associated with vascular disease


Nursing Diagnosis for Alzheimer's Disease : Risk for Injury
related to:
  • Disorientation, confusion, impaired decision making.
  • Unable to recognize / identify hazards in the environment.
  • Weakness, the muscles are not coordinated, the presence of seizure activity.

Intervention
  1. Help the people closest to identify the risk of hazards that may arise.
  2. Assess the degree of impaired ability of competence emergence of impulsive behavior and a decrease in visual perception.
  3. Eliminate / minimize sources of hazards in the environment
  4. Divert attention to a client when agitated or dangerous behaviors like getting out of bed by climbing the fence bed.

Rational:
  1. Impairment of visual perception increase the risk of falling.
  2. An impaired cognitive and perceptual disorders are beginning to experience the trauma as a result of the inability to take responsibility for basic security capabilities, or evaluating a particular situation.
  3. Identify potential risks in the environment and heighten awareness so that caregivers more aware of the danger.
  4. Maintain security by avoiding a confrontation that could improve the behavior / increase the risk for injury.

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