DOMAIN 11. Safety/ProtectionFreedom from danger, physical injury, or immune system damage; preservation from loss; and protection of safety and security | ||
Class 1. InfectionHost responses following pathogenic invasion | ||
Code | Diagnosis | Page |
00004 | Risk for infection | 379 |
Class 2. Physical injuryBodily harm or hurt | ||
Code | Diagnosis | Page |
00031 | Ineffective airway clearance | 380 |
00039 | Risk for aspiration | 381 |
00206 | Risk for bleeding | 382 |
00219 | Risk for dry eye | 383 |
00155 | Risk for falls | 384 |
00035 | Risk for injurya | 386 |
00245 | Risk for corneal injurya | 387 |
00087 | Risk for perioperative positioning injurya | 388 |
00220 | Risk for thermal injurya | 389 |
00250 | Risk for urinary tract injurya | 390 |
00048 | Impaired dentition | 391 |
00045 | Impaired oral mucous membrane | 392 |
00247 | Risk for impaired oral mucous membrane | 394 |
00086 | Risk for peripheral neurovascular dysfunction | 395 |
00249 | Risk for pressure ulcer | 396 |
00205 | Risk for shock | 398 |
00046 | Impaired skin integrity | 399 |
00047 | Risk for impaired skin integrity | 400 |
00156 | Risk for sudden infant death syndrome | 401 |
00036 | Risk for suffocation | 402 |
00100 | Delayed surgical recovery | 403 |
00246 | Risk for delayed surgical recovery | 404 |
00044 | Impaired tissue integrity | 405 |
00248 | Risk for impaired tissue integrity | 406 |
00038 | Risk for trauma | 407 |
00213 | Risk for vascular trauma | 409 |
Class 3. ViolenceThe exertion of excessive force or power so as to cause injury or abuse | ||
Code | Diagnosis | Page |
00138 | Risk for other-directed violence | 410 |
00140 | Risk for self-directed violence | 411 |
00151 | Self-mutilation | 412 |
00139 | Risk for self-mutilation | 414 |
00150 | Risk for suicide | 416 |
Class 4. Environmental hazardsSources of danger in the surroundings | ||
Code | Diagnosis | Page |
00181 | Contamination | 418 |
00180 | Risk for contamination | 420 |
00037 | Risk for poisoning | 421 |
Class 5. Defensive processesThe processes by which the self protects itself from the nonself | ||
Code | Diagnosis | Page |
00218 | Risk for adverse reaction to iodinated contrast media | 422 |
00217 | Risk for allergy response | 423 |
00041 | Latex allergy response | 424 |
00042 | Risk for latex allergy response | 425 |
Class 6. ThermoregulationThe physiological process of regulating heat and energy within the body for purposes of protecting the organism | ||
Code | Diagnosis | Page |
00005 | Risk for imbalanced body temperature | 426 |
00007 | Hyperthermia | 427 |
00006 | Hypothermia | 428 |
00253 | Risk for hypothermia | 430 |
00254 | Risk for perioperative hypothermia | 432 |
00008 | Ineffective thermoregulation | 433 |
a The editors acknowledge these concepts are not in alphabetical order, but a decision was made to maintain all “Risk for injury” diagnoses in sequential order.
Domain 11. Safety/Protection Class 1. Infection
00004
Risk for infection
(1986, 2010, 2013; LOE 2.1)
Risk Factors
- Chronic Illness (e.g., Diabetes Mellitus)
- Inadequate vaccination
- Insufficient knowledge to avoid exposure to pathogens
- Invasive procedure
- Malnutrition
- Obesity
Inadequate Primary Defenses
- Alteration in peristalsis
- Alteration in pH of secretions
- Alteration in skin integrity
- Decrease in ciliary action
- Premature rupture of amniotic membrane
- Prolonged rupture of amniotic membrane
- Smoking
- Stasis of body fluids
Inadequate Secondary Defenses
- Decrease in hemoglobin
- Immunosuppression
- Leukopenia
- Suppressed inflammatory response (e.g., IL-6, CRP)
- Inadequate vaccination
Increased Environmental Exposure to Pathogens
- Exposure to disease outbreak
Original literature support available at www.nanda.org
Domain 11. Safety/Protection Class 2. Physical Injury
00031
Ineffective airway clearance
(1980, 1996, 1998)
Defining Characteristics
- Absence of cough
- Adventitious breath sounds
- Alteration in respiratory pattern
- Alteration in respiratory rate
- Cyanosis
- Difficulty verbalizing
- Diminished breath sounds
- Dyspnea
- Excessive sputum
- Ineffective cough
- Orthopnea
- Restlessness
- Wide-eyed look
Related Factors
Environmental
- Exposure to smoke
- Second-hand smoke
- Smoking
Obstructed Airway
- Airway spasm
- Chronic obstructive pulmonary disease
- Exudate in the alveoli
- Excessive mucus
- Foreign body in airway
- Hyperplasia of the bronchial walls
- Presence of artificial airway
- Retained secretions
Physiological
- Allergic airway
- Asthma
- Infection
- Neuromuscular impairment
Domain 11. Safety/Protection Class 2. Physical Injury
00039
Risk for aspiration
(1988, 2013)
Risk Factors
- Barrier to elevating upper body
- Decrease in gastrointestinal motility
- Decrease in level of consciousness
- Delayed gastric emptying
- Depressed gag reflex
- Enteral feedings
- Facial surgery
- Facial trauma
- Impaired ability to swallow
- Incompetent lower esophageal sphincter
- Increase in gastric residual
- Increase in intragastric pressure
- Ineffective cough
- Neck surgery
- Neck trauma
- Oral surgery
- Oral trauma
- Presence of oral/nasal tube (e.g., tracheal, feeding)
- Treatment regimen
- Wired jaw
Domain 11. Safety/Protection Class 2. Physical Injury
00206
Risk for bleeding
(2008, 2013; LOE 2.1)
Risk Factors
- Aneurysm
- Circumcision
- Disseminated intravascular coagulopathy
- Gastrointestinal condition (e.g., ulcer, polyps, varices)
- History of falls
- Impaired liver function (e.g., cirrhosis, hepatitis)
- Inherent coagulopathy (e.g., thrombocytopenia)
- Insufficient knowledge of bleeding precautions
- Postpartum complications (e.g., uterine atony, retained placenta)
- Pregnancy complication (e.g., premature rupture of membranes, placenta previa/abruption, multiple gestation)
- Trauma
- Treatment regimen
Original literature support available at www.nanda.org
Domain 11. Safety/Protection Class 2. Physical Injury
00219
Risk for dry eye
(2010, 2013; LOE 2.1)
Risk Factors
- Aging
- Autoimmune disease (e.g., rheumatoid arthritis, diabetes mellitus, thyroid disease)
- Contact lens wearer
- Environmental factor (e.g., air conditioning, excessive wind, sunlight exposure, air pollution, low humidity)
- Female gender
- History of allergy
- Hormonal change
- Lifestyle choice (e.g., smoking, caffeine use, prolonged reading)
- Mechanical ventilation
- Neurological lesion with sensory or motor reflex loss (e.g., lagophthalmos, lack of spontaneous blink reflex)
- Ocular surface damage
- Treatment regimen
- Vitamin A deficiency
Original literature support available at www.nanda.org
Domain 11. Safety/Protection Class 2. Physical Injury
00155
Risk for falls
(2000, 2013)
Risk Factors
Adults
- Age ≥ 65 years
- History of falls
- Living alone
- Lower limb prosthesis
- Use of assistive device (e.g., walker, cane, wheelchair)
Children
- Absence of stairway gate
- Absence of window guard
- Age ≤ 2 years
- Inadequate supervision
- Insufficient automobile restraints
- Male gender when < 1 year of age
Cognitive
- Alteration in cognitive functioning
Environment
- Cluttered environment
- Exposure to unsafe weather-related condition (e.g., wet floors, ice)
- Insufficient lighting
- Insufficient anti-slip material in bathroom
- Unfamiliar setting
- Use of restraints
- Use of throw rugs
Pharmaceutical Agents
- Alcohol consumption
- Pharmaceutical agent
Physiological
- Acute illness
- Alteration in blood glucose level
- Anemia
- Arthritis
- Condition affecting the foot
- Decrease in lower extremity strength
- Diarrhea
- Difficulty with gait
- Faintness when extending neck
- Faintness when turning neck
- Hearing impairment
- Impaired balance
- Impaired mobility
- Incontinence
- Neoplasm
- Neuropathy
- Orthostatic hypotension
- Postoperative recovery period
- Proprioceptive deficit
- Sleeplessness
- Urinary urgency
- Vascular disease
- Visual impairment
Domain 11. Safety/Protection Class 2. Physical Injury
00035
Risk for injury
(1978, 2013)
Risk Factors
External
- Alteration in cognitive functioning
- Alteration in psychomotor functioning
- Compromised nutritional source (e.g., vitamins, food types)
- Exposure to pathogen
- Exposure to toxic chemical
- Immunization level within community
- Nosocomial agent
- Physical barrier (e.g., design, structure, arrangement of community, building, equipment)
- Unsafe mode of transport
Internal
- Abnormal blood profile
- Alteration in affective orientation
- Alteration in sensation (resulting from spinal cord injury, diabetes mellitus, etc.)
- Autoimmune dysfunction
- Biochemical dysfunction
- Effector dysfunction
- Extremes of age
- Immune dysfunction
- Impaired primary defense mechanisms (e.g., broken skin)
- Malnutrition
- Sensory integration dysfunction
- Tissue hypoxia
Domain 11. Safety/Protection Class 2. Physical Injury
00245
Risk for corneal injury
(2013; LOE 2.1)
Risk Factors
- Blinking <5 times per minute
- Exposure of the eyeball
- Glasgow Coma Scale score <7
- Intubation
- Mechanical ventilation
- Periorbital edema
- Pharmaceutical agent
- Prolonged hospitalization
- Tracheostomy
- Use of supplemental oxygen
Original literature support available at www.nanda.org
Domain 11. Safety/Protection Class 2. Physical Injury
00087
Risk for perioperative positioning injury
(1994, 2006, 2013; LOE 2.1)
Risk Factors
- Disorientation
- Edema
- Emaciation
- Immobilization
- Muscle weakness
- Obesity
- Sensoriperceptual disturbance from anesthesia
Original literature support available at www.nanda.org
Domain 11. Safety/Protection Class 2. Physical Injury
00220
Risk for thermal injury
(2010, 2013; LOE 2.1)
Risk Factors
- Alteration in cognitive functioning
- Extremes of age
- Extremes of environmental temperature
- Fatigue
- Inadequate protective clothing (e.g., flame-retardant sleepwear, gloves, ear covering)
- Inadequate supervision
- Inattentiveness
- Insufficient knowledge of safety precautions (patient, caregiver)
- Intoxication (alcohol, drug)
- Neuromuscular impairment
- Neuropathy
- Smoking
- Treatment regimen
- Unsafe environment
Original literature support available at www.nanda.org
Domain 11. Safety/Protection Class 2. Physical Injury
00250
Risk for urinary tract injury
(2013; LOE 2.1)
Risk Factors
- Condition preventing ability to secure catheter (e.g., burn, trauma, amputation)
- Long-term use of urinary catheter
- Multiple catheterizations
- Retention balloon inflated to ≥30 ml
- Use of large caliber urinary catheter
Original literature support available at www.nanda.org
Domain 11. Safety/Protection Class 2. Physical Injury
00048
Impaired dentition
(1998)
Defining Characteristics
- Abraded teeth
- Absence of teeth
- Dental caries
- Enamel discoloration
- Erosion of enamel
- Excessive oral calculus
- Excessive oral plaque
- Facial asymmetry
- Halitosis
- Incomplete tooth eruption for age
- Loose tooth
- Malocclusion
- Premature loss of primary teeth
- Root caries
- Tooth fracture
- Tooth misalignment
- Toothache
Related Factors
- Barrier to self-care
- Bruxism
- Chronic vomiting
- Difficulty accessing dental care
- Economically disadvantaged
- Excessive intake of fluoride
- Excessive use of abrasive oral cleaning agents
- Genetic predisposition
- Habitual use of staining substance (e.g., coffee, red wine, tea, tobacco)
- Insufficient dietary habits
- Insufficient knowledge of dental health
- Insufficient oral hygiene
- Malnutrition
- Oral temperature sensitivity
- Pharmaceutical agent
Domain 11. Safety/Protection Class 2. Physical Injury
00045
Impaired oral mucous membrane
(1982, 1998, 2013)
Defining Characteristics
- Bad taste in mouth
- Bleeding
- Cheilitis
- Coated tongue
- Decrease in taste sensation
- Desquamation
- Difficulty eating
- Difficulty speaking
- Enlarged tonsils
- Exposure to pathogen
- Geographic tongue
- Gingival hyperplasia
- Gingival pallor
- Gingival pocketing deeper than 4 mm
- Gingival recession
- Halitosis
- Hyperemia
- Impaired ability to swallow
- Macroplasia
- Mucosal denudation
- Oral discomfort
- Oral edema
- Oral fissure
- Oral lesion
- Oral mucosal pallor
- Oral nodule
- Oral pain
- Oral papule
- Oral ulcer
- Oral vesicles
- Presence of mass (e.g., hemangioma)
- Purulent oral-nasal drainage
- Purulent oral-nasal exudates
- Smooth atrophic tongue
- Spongy patches in mouth
- Stomatitis
- White patches in mouth
- White plaque in mouth
- White, curd-like oral exudate
- Xerostomia
Related Factors
- Alcohol consumption
- Allergy
- Alteration in cognitive functioning
- Autoimmune disease
- Autosomal disorder
- Barrier to dental care
- Barrier to oral self-care
- Behavior disorder (e.g., attention deficit, oppositional defiant)
- Chemical injury agent (e.g., burn, capsaicin, methylene chloride, mustard agent)
- Cleft lip
- Cleft palate
- Decrease in hormone level in women
- Decrease in platelets
- Decrease in salivation
- Dehydration
- Depression
- Immunodeficiency
- Immunosuppression
- Infection
- Insufficient knowledge of oral hygiene
- Insufficient oral hygiene
- Loss of oral support structure
- Malnutrition
- Mechanical factor (e.g., ill-fitting dentures, braces, endotracheal/nasogastric tube, oral surgery)
- Mouth breathing
- Nil per os (NPO) >24 hours
- Oral trauma
- Smoking
- Stressors
- Syndrome (e.g., Sjögren’s)
- Treatment regimen
Original literature support available at www.nanda.org
Domain 11. Safety/Protection Class 2. Physical Injury
00247
Risk for impaired oral mucous membrane
(2013; LOE 2.1)
Risk Factors
- Alcohol consumption
- Allergy
- Alteration in cognitive functioning
- Autoimmune disease
- Autosomal disorder
- Barrier to dental care
- Barrier to oral self-care
- Behavior disorder (e.g., attention deficit, oppositional defiant)
- Chemotherapy
- Decrease in hormone level in women
- Economically disadvantaged
- Immunodeficiency
- Immunosuppression
- Inadequate nutrition
- Infection
- Insufficient knowledge of oral hygiene
- Insufficient oral hygiene
- Mechanical factor (e.g., orthodontic appliance, device for ventilation or food, ill-fitting dentures)
- Radiation therapy
- Smoking
- Stressors
- Surgical procedure
- Syndrome (e.g., Sjögren’s)
- Trauma
Original literature support available at www.nanda.org
Domain 11. Safety/Protection Class 2. Physical Injury
00086
Risk for peripheral neurovascular dysfunction
(1992, 2013)
Risk Factors
- Burns
- Fracture
- Immobilization
- Mechanical compression (e.g., tourniquet, cast, brace, dressing, restraint)
- Orthopedic surgery
- Trauma
- Vascular obstruction
Domain 11. Safety/Protection Class 2. Physical Injury
00249
Risk for pressure ulcer
(2013; LOE 2.2)

Full access? Get Clinical Tree

