00031 Ineffective airway clearance

00031 Ineffective airway clearance

Definition of the NANDA label Inability to clear secretions or obstructions from the respiratory tract to keep the airways clear. Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. Defining characteristics Decrease in respiratory sounds. Changes in respiratory rate and rhythm. Dyspnea and orthopnea. Added respiratory noises (rales, rhonchi, … Read more

00035 Risk for injury

00035 Risk for injury

Definition of the NANDA label Risk of injury as a consequence of the interaction of environmental conditions with the adaptive and defensive resources of the person. Susceptible to physical damage due to environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health. Risk factors External (environmental) Biological • Community health and … Read more

00036 Risk for suffocation

00036 Risk for suffocation

Definition of the NANDA label State in which the individual is in clear danger of accidental suffocation (insufficient availability of air to inhale). Susceptible to inadequate air availability for inhalation, which may compromise health. Risk factors External (environmental) • Children’s accessibility to plastic bags and small objects that can be put in the nose or … Read more

00038 Risk for physical trauma

00038 Risk for physical trauma

Definition of the NANDA label Risk for physical trauma is situation in which there is a risk of accidental tissue injuries such as fractures, wounds or burns. Susceptible to physical injury of sudden onset and severity which require immediate attention. Risk factors External (environmental) Child safety flaws • Children who play with matches, lighters, candles, … Read more

00039 Risk for aspiration

00039 Risk for aspiration

Definition of the NANDA label Situation in which the individual runs the risk of oropharyngeal or gastrointestinal secretions, solid or liquid foods, entering the tracheobronchial tract, due to a dysfunction or an absence of normal protection mechanisms. Susceptible to entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids to the tracheobronchial passages, which may compromise … Read more

00043 Ineffective protection

00043 Ineffective protection

Definition of the NANDA label Situation in which the individual has a decreased ability to protect himself from internal and external threats, such as illness and injury. Decrease in the ability to guard self from internal or external threats such as illness or injury. Defining characteristics • Immunodeficiency status. • Delayed healing. • Coagulation disorders. … Read more

00044 Impaired tissue integrity

00044 Impaired tissue integrity

Definition of the NANDA label State in which the individual experiences a lesion of the mucous or corneal membranes, integumentary or subcutaneous tissue. It is a situation in which a body tissue is altered. Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament. Defining characteristics Tissue … Read more

00045 Impaired oral mucous membrane integrity

00045 Impaired oral mucous membrane integrity

Definition of the NANDA label State in which the individual presents alterations in the integrity of the lips and soft tissues of the oral cavity. Injury to the lips, soft tissue, buccal cavity, and/or oropharynx. Defining characteristics • Purulent drainage or exudate. • Gingival recession, pockets larger than 4 mm. • Enlargement of the tonsils … Read more

00046 Impaired skin integrity

00046 Impaired skin integrity

Definition of the NANDA label State in which the individual presents alterations of the epidermis, the dermis or both. Altered epidermis and/or dermis. Defining characteristics • Alteration of the surface of the skin (epidermis). • Destruction of the layers of the skin (dermis). • Invasion of body structures. Related factors External • Alteration of the … Read more

00047 Risk for impaired skin integrity

00047 Risk for impaired skin integrity

Definition of the NANDA label State in which the individual’s skin is in danger of being altered. Susceptible to alteration in epidermis and/or dermis, which may compromise health. Risk factors External (environmental) • Irritating chemicals. • Body excretions or secretions. • Mechanical factors (pressure, shear, clamping). • Radiation. • Physical immobilization. • Humidity. • Hypothermia … Read more