11: Safety/Protection

Domain 11
Safety/Protection






























































































































































































































DOMAIN 11. Safety/Protection
Freedom from danger, physical injury, or immune system damage; preservation from loss; and protection of safety and security
Class 1. Infection
Host responses following pathogenic invasion
Code Diagnosis Page
00004 Risk for infection 379
Class 2. Physical injury
Bodily 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. Violence
The 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 hazards
Sources of danger in the surroundings
Code Diagnosis Page
00181 Contamination 418
00180 Risk for contamination 420
00037 Risk for poisoning 421
Class 5. Defensive processes
The 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. Thermoregulation
The 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)

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Mar 21, 2017 | Posted by in NURSING | Comments Off on 11: Safety/Protection

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