00043 Ineffective Protection

Domain 1: health promotion
Class 2: Health Management
Diagnostic Code: 00043
Nanda label: ineffective protection
Diagnostic focus: protection
Approved 1990 • Revised 2017, 2020 • Evidence level 3.2

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « ineffective protection » is defined as: decreased ability to protect themselves from internal or external threats, such as diseases or injuries.

Definite characteristics

  • Sweating alteration
  • Anorexia
  • Internal feeling of intense cold
  • cough
  • Disorientation
  • Dyspnea
  • Express Pruritus
  • Fatigue
  • deterioration of physical mobility
  • Tissue healing deterioration
  • Insomnia
  • Leukopenia
  • Low level of serum hemoglobin
  • Deadaptive response to stress
  • Neurosensory deterioration
  • Pressure injury
  • Psychomotor agitation
  • Thrombocytopenia
  • Weakness

Related factors

  • Depressive symptoms
  • Difficulty in managing a complex therapeutic regime
  • Desperateness
  • Inadequate vaccination
  • Low self -efficacy
  • Malnutrition
  • Loss of physical condition
  • Inappropriate use of substances

Associated problems

  • Blood coagulation disorders
  • Immune system diseases
  • Neoplasms
  • Pharmacological preparations
  • Therapeutic regime

Suggestions of use

  • (a) Whenever possible, use a more specific label, such as infection, deterioration of skin integrity, deterioration of tissue integrity, deterioration of oral mucosa or fatigue, (b) ineffective protection should not be used as a “miscellaneous” diagnosis for immunosuppressed patients or who have altered coagulation factors.
  • For example, authors do not recommend the routine use of ineffective protection during labor.

Suggested alternative diagnostics

  • Committed family coping
  • Incapacitating family coping
  • Peripheral neurovascular dysfunction, risk of
  • Infection, risk of
  • Cutaneous integrity, risk of deterioration of
  • Transoperative postural injury, risk of
  • injury, risk of
  • Paternity, deterioration of the

NOC Results

  • Blood coagulation: point to which blood is coagula within a normal time period
  • Immunization behavior: personal actions to be vaccinated and prevent a contagious disease
  • Symptom control: personal actions to minimize adverse changes perceived in physical and emotional functioning
  • Wound healing: First intention: scope of cell regeneration and tissue after an intentional closure
  • Immune state: natural and acquired resistance, adequately directed to internal and external antigens
  • Neurological status: Peripheral: capacity of the peripheral nervous system to transmit impulses from and to the central nervous system
  • Nutritional status: degree in which nutrients are available to meet metabolic needs
  • Respiratory status: air movement inside and outside the lungs and carbon and oxygen exchange exchange at alveolar level
  • Tissue integrity: mucous skin and membranes: Structural integrity and normal physiological function of the skin and mucous membranes
  • Mobility: Ability to move intentionally in its own environment, independently or with an auxiliary device
  • Fatigue level: gravity of prolonged and generalized fatigue, as observed or reported
  • Cognitive orientation: Ability to correctly identify person, time and place

Evaluation objectives and criteria

  • • Demonstrates immune status, as manifested by the following indicators (specify from 1 to 5: severe, substantial, moderate, mild or none):
    • Recurrent infections
    • Chronic fatigue
  • • Demonstrates immune state, as manifested by the following indicators (specify from 1 to 5: severely, substantially, moderately, slightly or not compromised):
    • Current immunizations
    • Antibody titles
    • Leukocytic formula
    • Complement levels, T4 leukocytes and T8 leukocytes

Other examples

  • • Demonstrates behaviors that reduce the risk of injury, infection or bleeding
  • • Report the first signs and symptoms of injury, infection or hemorrhage
  • • It remains without signs or symptoms of injury, infection or bleeding
  • • Verbally express a security plan for yourself and their children (for example, obtain a restriction order)
  • • Demonstrates an adequate nutritional status
  • • Present a respiratory state within normal limits

NIC Interventions

  • Nutrition advice: use of an interactive help process, focused on the need to modify the diet
  • Ventilation assistance: promotion of a spontaneous respiratory pattern
  • optimal, which achieves the maximum possible exchange of oxygen and carbon dioxide in the lungs
  • Infection control: decrease in the acquisition and transmission of infectious agents
  • Wound care: prevention of wound complications and help for cure
  • Incision site care: cleaning, surveillance and promotion of healing a closed wound by suture, clips or staples
  • Health Education: Preparation and supply of information and teachings to facilitate the voluntary adaptation of health behaviors in individuals, families, groups or communities
  • Risk identification: Analysis of possible risk factors, determination of health risks and prioritization of risk reduction strategies for a person or group
  • Energy management: Regulation of energy use to treat or prevent fatigue and optimize operation
  • Immunization/Vaccination Management: Surveillance of the immunization state, facilitation of access to vaccines and provision of vaccines to prevent contagious diseases
  • Pressure management: pressure reduction on body parts
  • Peripheral sensation management: prevention or reduction of injuries or discomfort of patients with sensory alterations
  • Management of eating disorders: prevention and treatment of serious diet restrictions and excessive exercise, or binge and liquid and liquid purges
  • Reality orientation: Promotion of patient consciousness of his personal identity, time and environment
  • Hemorrhage prevention: reduction of stimuli that can cause bleeding or bleeding in patients at risk
  • Infection protection: Prevention and early detection of infections in a patient at risk
  • Exercise therapy: Desembling: Promotion and patient assistance to walk, in order to maintain or reestablish the voluntary and autonomous functions of the organism during the treatment and recovery of the disease or injury
  • Exercise therapy: balance: use of specific activities, postures and movements, to maintain, improve or restore balance
  • Nutritional therapy: Food and liquid administration that support the metabolic processes of a malnourished or with high risk of malnutrition
  • Respiratory surveillance: Collection and analysis of patient data to guarantee the permeability of the respiratory tract and the appropriate gas exchange

Nursing Activities

  • Since there are so many risk factors for this diagnosis, there are many possible nursing activities. The activities that are focused on the specific risk factors of the patient should be chosen.

Infection prevention

  • See nursing activities for the diagnosis of infection, risk of.
  • Injury prevention
  • See nursing activities for the diagnosis of injury risk.
  • • Monitor the safety of the articles that visitors carry
  • • Eliminate sharp objects and other potential weapons in the area where the patient is located
  • • Key warehouses and rooms with services control

Hemorrhage prevention

  • • Evaluate the degree of patient bleeding risk
Patient and family education
  • • Advise the patient to carry a medical identification bracelet and notify the dentist or doctor
  • • Indicate the patient to avoid trauma (for example, contact sports, sharp objects, hard toothbrush)
  • • Teach the patient the signs and symptoms of a hemorrhage and when he should notify his occurrence
  • • Teach the patient first aid for hemorrhages

Transoperative and Posoperative

See nursing activities for the diagnosis of risk of transoperative postural injury.

  • • Monitor oxygenation
  • • Monitor and record vital signs every 15 minutes or more often, as required
  • • Monitor urinary elimination
  • • Control the degree of consciousness
  • • Monitor the surgical area
  • • Evaluate pain every 15 minutes during the first hour
  • • Observe if there is patient skin injury after the use of electrocirugia
  • • Register and inform about allergies
  • • Inspect the patient’s skin in the contact zone with the mattress
  • • motivate deep aspirations and cough
  • • Make sure the team works correctly
  • • Help in the count of sponges, scalpels and instrumental

Patient and family education

  • • Provide information on community resources and support groups
Collaboration activities
  • • Consult the nutritionist about suggestions to improve nutrition
  • • Consult with social services to identify appropriate psychological advisors to channel the patient
  • • Explore with the patient ways to improve rest and sleep
  • • Help the patient achieve an optimal level of sleep, rest, nutrition, activity and stress management
  • • Talk to the patient and family about relaxation techniques
  • • Help the patient and the family identify and plan an adequate exercise program

At home

  • • Determine if there is abuse
  • • Only some of the previous nursing activities are suitable for home use
  • • Teach to handle and safely store food, especially in the case of immunosuppressed patients

Babies and Children

  • • In the case of premature infants and with low birth weight, use a gauze soaked in alcohol to wash your hands; It is necessary to wear gloves for patient care
  • • Do not routinely use topical antibiotic ointments in the case of premature infants
  • • Motivate breastfeeding to the maternal breast in the case of infants with low birth weight

Older people

  • • Help the patient adapt an exercise program according to their functional capacity
  • • Recommend vitamin and mineral supplements