S3 · Likely to get hurt
Risk Safety and protection
Definition
The person's condition or surroundings raise the chance of accidental harm.- Confusion
- weakness
- hazards
- poor sight
- unsafe equipment
- Near misses
- bumps
- unsafe movements
- cluttered space
📋 Scenario
A confused patient climbs over the bed rails.
Subjective (S): "I need to get out and go home."
Objective (O): Confused; climbs over bed rails; unsteady; bed alarm sounding.
Assessment tools for this scenario: CP-SAFE Safety & Falls Score CP-OLDER Older Adult Check
Validated scales to consider: Morse Fall Scale, 4AT / CAM, Mini-Cog
**CarePath diagnosis:** Likely to get hurt related to confusion and weakness (risk factors); no signs of the problem are present yet.
**Interventions and rationale**
| Intervention | Rationale |
|---|---|
| Remove hazards. | Removing hazards such as clutter and unsafe objects lowers the chance of tripping or bumping. |
| Supervise. | A confused, unsteady patient cannot judge danger, so close supervision lets staff step in before injury. |
| Meet needs early. | Needs such as toileting, thirst and pain can drive restlessness, so meeting them early lessens the urge to leave the bed. |
| Use safe equipment. | Safe equipment, such as a low bed and a working bed alarm, reduces the height of any fall and alerts staff quickly. |
| Reassure and reorient. | Calm reassurance and reminders of place and time lower fear and confusion, which reduces attempts to leave. |
**Expected outcomes**
- No injuries.
- Stays in bed or sits safely with supervision.
- Needs anticipated.
- Confusion treated and patient calmer.
**Linking the data to the diagnosis**
The confused patient says they need to get out and go home, climbs over the bed rails, is unsteady, and the bed alarm is sounding. No injury has happened yet, so the diagnosis is a risk one resting on confusion and weakness, not an actual injury. It is related to likely to fall, but here the danger includes climbing and other unsafe movements. The plan aims for no injuries, the patient staying in bed or sitting safely with supervision, needs anticipated, and confusion treated so the patient is calmer.
CarePath diagnosis
Likely to get hurt related to confusion and weakness (risk factors); no signs of the problem are present yet.
Interventions and rationale
Listed in priority order.
| Intervention | Rationale |
|---|---|
| 1. Remove hazards. | Removing hazards such as clutter and unsafe objects lowers the chance of tripping or bumping. |
| 2. Supervise. | A confused, unsteady patient cannot judge danger, so close supervision lets staff step in before injury. |
| 3. Meet needs early. | Needs such as toileting, thirst and pain can drive restlessness, so meeting them early lessens the urge to leave the bed. |
| 4. Use safe equipment. | Safe equipment, such as a low bed and a working bed alarm, reduces the height of any fall and alerts staff quickly. |
| 5. Reassure and reorient. | Calm reassurance and reminders of place and time lower fear and confusion, which reduces attempts to leave. |
Expected outcomes
- No injuries.
- Stays in bed or sits safely with supervision.
- Needs anticipated.
- Confusion treated and patient calmer.
Linking the data to the diagnosis
The confused patient says they need to get out and go home, climbs over the bed rails, is unsteady, and the bed alarm is sounding. No injury has happened yet, so the diagnosis is a risk one resting on confusion and weakness, not an actual injury. It is related to likely to fall, but here the danger includes climbing and other unsafe movements. The plan aims for no injuries, the patient staying in bed or sitting safely with supervision, needs anticipated, and confusion treated so the patient is calmer.