00043 Ineffective protection

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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.
• Decreased response to stress.
• Neurosensory alterations.
• Dyspnea and sweating.
• Itching.
• Agitation and insomnia.
• Weakness.
• Immobility.
• Pressure ulcers (decubitus).

Related factors

• Extreme ages.
• Inadequate nutrition.
• Alcohol abuse.
• Hematological disorders (anemia, leukopenia, thrombocytopenia, coagulopathy).
• Effects of medications (antineoplastics, corticosteroids, immunosuppressants, anticoagulants).
• Aftermath of treatments (surgery, radiotherapy).
• Cancer and immune diseases.

At risk population

• Extremes of age

Associated condition

• Abnormal blood profile
• Cancer
• Immune disorder
• Pharmaceutical agent
• Treatment regimen

NOC

• Vaccination behavior.
• State of coagulation.
• Fetal status: perinatal.
• Fetal status: prenatal.
• Immune status.
• Neurological state: consciousness.
• Protection from abuse.
• Resistance.

NIC

• Identification of risks.
• Immunization / vaccination management.
• Precautions with bleeding.
• Electronic fetal monitoring during labor.
• Fetal monitoring: before delivery.
• Obstetric ultrasound.
• Allergy management.
• Protection against infection.
• Care in the emergency.
• Environmental management: safety.
• Improved cerebral perfusion.
• Neurological monitoring.
• Helps in protecting against abuse.
• Support in the protection against abuse.
• Energy management.

This diagnosis will retire from the NANDA-I Taxonomy in the 2021-2023 edition unless additional work is completed to bring it up to a level of evidence 2.1 or higher.

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