Domain 1.Health promotion
Class 2. Health management
Diagnostic Code: 00043
Nanda label: Ineffective protection
Diagnostic focus: Protection
Nursing diagnosis is the process of identifying and labelling the nursing problem caused by a patient’s health condition, based on the medical record, laboratory test results, and a physical examination. Ineffective protection is a common nursing diagnosis and is defined as difficulty or inability in protecting oneself from harm due to physical or mental factors. This nursing diagnosis is appropriate when a patient is diagnosed with a mental or physical impairment that impedes their ability to protect themselves.
NANDA Nursing Diagnosis Definition
In the NANDA International (NANDA-I) Taxonomy II nursing diagnosis list, Ineffective protection is defined as the state in which an individual is unable to take appropriate measures for self-protection. The defining characteristics of this diagnosis include confusion, disorientation, frustration, fear, and impaired judgment.
The following are the subjective and objective characteristics of ineffective protection:
- Subjective: Complaints of feeling unsafe, disorientation, absentmindedness, threat, danger, insecurity and deficiencies in decision making.
- Objective: Poor awareness of personal safety, wandering, exposure to environmental hazards, frequent falls, inability to recognize dangerous situations, and impaired judgment.
There are several factors that may contribute to an individual’s feeling of of Ineffective protection:
- Cognitive Impairment: Patients with cognitive impairments such as dementia, mental illness, or severe intellectual disability may have difficulty understanding abstract concepts and recognizing dangers.
- Sensory Deficiencies: Patients with limited sight, hearing, or touch can’t always identify eminent threats. These patients may not be able to sense the presence of an imminent danger and thus cannot adequately protect themselves.
- Physical Impairment: Patients who are physically impaired due to injury, chronic pain or paralysis often require assistance to navigate their environment.
- Environmental Hazards: Patients living in unsafe or cramped environments can be exposed to numerous unwanted intrusions, accidents, and risk of exploitation or harm.
- Psychological Stressors: Patients with certain psychological stressors such as extreme grief or depression may be unable to comprehend their surroundings and the dangers they pose.
Nursing diagnosis of ineffective protection often coexist with the following conditions:
- Malnutrition: Malnourishment hinders the body’s ability to regenerate vital tissues and can contribute to a lack of energy. This can negatively influence the patient’s ability to attend to the needs of day-to-day living.
- Substance Abuse: Drug and alcohol abuse results in lowered inhibitions and poor judgement, thereby increasing the risk of accidents or criminal victimization.
- Social Isolation: Patients living alone or in socially isolated environments are at risk of any number of hazards including physical, emotional, and financial abuse.
- High Mobility or Restlessness: Patients in need of continued supervision may be at greater risk of injury due to their restlessness.
Suggestions for Use
Nurses should assess the potential risks posed to the patient and take appropriate action to decrease those risks. Some ways in which nurses can assist patients suffering from ineffective protection include:
- Monitoring environmental settings for hazardous or dangerous conditions.
- Performing physical evaluations to assess patient mobility and balance.
- Providing education on safety measures applicable to the patient’s environment.
- Frequent assessment of patient mood, cognitive function, headaches, chest pain, or other signs of distress.
- Referring the patient to physical and occupational therapy, as needed.
- Referrals to social service agencies to provide advice, care planning, and resources.
- Exploring options for assistive devices or home modifications for higher level of protection.
Suggested Alternative NANDA Nursing Diagnosis
In addition to Ineffective protection, nurses may also diagnose one or more alternative NANDA nursing diagnoses, depending on the patient’s particular circumstances. These include:
- Impaired Safety Awareness: Ability of the patient to identify and avoid dangerous situations.
- Impaired Physical Mobility: Diminished ability to independently and safely move or position oneself to protect against hazardous situations.
- Risk-Prone Health Behavior: A tendency toward behaviors that increase the risk of injury, illness, or death.
- Disturbed Sensory Perception: Impairment in the patient’s ability to accurately interpret visual, auditory or tactile information.
- Ineffective Coping: The patient’s inadequate response to a psychological stressor or crisis.
- Risk for Injury: The patient’s likelihood of becoming injured by his or her own actions or the actions of others.
When diagnosing a patient with Ineffective protection, nurses should be sure to consider any psychological, physical, and situational factors relevant to the patient’s particular case. It’s important to document all factors and observed behaviors in order to develop an appropriate plan of treatment. Nurses should also be aware that interventions should be tailored to the individual and should take into account any relevant cultural or spiritual beliefs and practices of the patient.
A successful intervention plan should aim to improve the outcomes listed below:
- Protection Status: The patient’s ability to identify and avoid dangers or provide protection to self and others.
- Mobility Level: The patient’s ability to move and position himself or herself to maintain a safe environment.
- Coping Status: The patient’s effectiveness in dealing with stressful events or crises.
- Mental Status: The patient’s alertness, attention, and orientation.
- Sensory Perception: Patient’s ability to accurately interpret information from the external environment.
Evaluation Objectives and Criteria
Nurses should evaluate the patient’s progress in improving the outcomes listed above according to the criteria below:
- Protection Status: The patient should demonstrate an increased ability to identify and avoid risks or provide protection to self and others.
- Mobility Level: The patient should exhibit improved mobility and balance.
- Coping Status: The patient should demonstrate increased confidence in deal with stressful events or crises.
- Mental Status: The patient should show good alertness, attention, and orientation.
- Sensory Perception: The patient should display a higher accuracy in interpreting external environment stimuli.
To achieve the goals mentioned above, the nurse should provide the following interventions:
- Safe Environment Teaching: Giving the patient instructions on how to identify and avoid dangerous situations.
- Orientation Therapy: Helping patient to understand his/her environment and to accurately interpret sensory data.
- safety Supervision: Providing direct supervision of patient when necessary to ensure safety.
- Restraints Use: Ensuring that the use of restraints appropriately when necessary.
- Assistive Devices: Assessing the patient’s need for assistive device and making necessary referrals.
- Resource Utilization: Facilitating connections to community resources and support services.
Nurses should perform the activities below to support the patient in meeting the goals and objectives:
- Perform physical assessment to monitor the patient’s safety.
- Review the patient’s medication profile and vital signs.
- Help the patient to formulate short and long term strategies for safely managing his/her environment.
- Provide training and instruction on the use of assistive devices, as needed.
- Encourage patient to interact positively with peers and family members whenever possible.
- Teach the patient problem solving skills related to safety and protection.
- Develop a plan of care to identify any potential and existing risks for the patient.
- Refer the patient to consult with mental health resources if needed.
Nursing diagnosis of ineffective protection is a commonly used diagnosis that affects a wide range of individuals. Nurses should assess each patient’s specific health, environmental, and psychological situation to develop an individualized intervention plan. With the appropriate interventions, patients can increase their safety awareness and reduce their risk of harm.
- What is Ineffective Protection? Ineffective protection is defined as the inability or difficulty in protecting oneself from harm due to physical or mental factors.
- What are some associated conditions of this diagnosis? Patients suffering from ineffective protection may also experience malnutrition, substance abuse, social isolation, or high mobility.
- What types of interventions can a nurse provide to help improve the patient’s condition? Interventions may include providing education on safety measures, making referrals to therapy or social services, or exploring options for assistive devices.
- What are the outcomes of effective interventions? Effective interventions should aim to improve the patient’s protection status, mobility level, coping status, mental status, and sensory perception.
- What criteria should the nurse use to evaluate the patient’s progress? The patient’s progress should be evaluated according to the same criteria as the desired outcomes, including protection status, mobility level, coping status, mental status, and sensory perception.