Ineffective Protection Nursing Care Plans Diagnosis and Interventions
Ineffective Protection NCLEX Review and Nursing Care Plans
Ineffective Protection is a NANDA nursing diagnosis that refers to a situation where an affected or ill individual is incapable of protecting oneself from internal and external harm (e.g., infection and injury).
Patients may have diminished self-protection capabilities and are more susceptible to acquiring opportunistic infections, especially those who have a compromised immune system (immunocompromised patients).
Nurse’s Role in the Care of Patients with Ineffective Protection
The nurse’s main role in protecting the patient’s well-being is through health promotion (i.e., being an educator). In cases where disease progression is inevitable and chronic disease is suspected, it is anticipated that the patient would become susceptible or vulnerable.
Patient susceptibility is frequently associated with inadequate protection of certain body systems, including the neurological, cardiovascular, endocrine, pulmonary, musculoskeletal, urinary, gastrointestinal, and endocrine systems.
These events suggest ineffective protection; therefore, patient safeguarding is a prime concern in assisting patients or clients in overcoming their weaknesses during rehabilitation, therapy, prognosis, or management.
Nursing care goals must be centered on recognizing etiological factors that characterize decreased self-protection abilities.
These may be observed through clinical manifestations such as fatigue, cognitive acuity, fractures, anemia, fever, pain, bleeding, nausea, etc. Evaluation of medical history and diagnostic tests also correspond to timely and accurate nursing interventions.
Specific roles of nurses under this nursing diagnosis:
- Nursing Assessment. The focus of nurse assessment should be on identifying clinical indications that indicate an increased patient risk. Clinical indicators of ineffective protection include:
- Alteration in the coagulation system
- Persistent Infections
- Visual acuity
- Nursing Planning and Intervention. The nurse formulates an effective care plan based on the effective evaluation of the patient’s signs and symptoms and behavioral responses.
- Nursing Evaluation. The nurse measures the patient’s degree of orientation and fatigue to modify the care plan to the patient’s tolerance and capacity.
Related Factors to Ineffective Protection
- Family history of malignancy/cancer
- Economic status
- Pre-existing conditions (e.g., hematological disorders, autoimmune diseases)
- Alcohol abuse
- Previous surgery
Causes of Ineffective Protection
- Malignancies. Cancer can weaken the immune system by suppressing or infiltrating the bone marrow (BM). Since BM is responsible for the innate immune system (e.g., natural killer cells, neutrophils, and phagocytes) and cells in the adaptive immune system, metastasis of the malignancy might impede its function and blood cell production. Moreover, its associated treatment, such as chemotherapy, can also cause immunosuppression due to the destruction of blood cells, including immune cells.
- Malnutrition. An unbalanced diet that does not match the patient’s nutritional requirements might be detrimental and increase their susceptibility to illness or infection. The inadequate absorption of macro and micronutrients in the body may stem from food deprivation or a secondary process resulting from an infectious, malignant, or inflammatory disease. Due to inadequate nutrient and energy intake, poor nutrition suppresses immune system functioning, resulting in anomalies in phagocyte function, cellular responses, cytokine production, complement system, antibody affinity, and responses.
- Coagulation disorders. The coagulation system limits the invasiveness of the pathogen and helps the innate immune system ward off infection. For instance, the fibrin mesh sequesters pathogens, whereas P-selectin facilitates neutrophil rolling at the site of inflammation. However, if the patient has coagulation disorders (excessive or deficient blood clot formation), the interaction of immune complexes may be disrupted or rendered inactive. Excessive activation of clotting factors, such as DIC, can contribute to ischemia and tissue damage.
- Autoimmune diseases, such as:
- Lupus. A chronic autoimmune disease that affects any organ of the body and produces antibodies (autoantibodies) against its own cells, tissues, and organs. These lead to an inflammatory response that can result in tissue damage, pain, and organ failure.
- Type 1 Diabetes. Juvenile diabetes is a metabolic condition in which the body cannot produce insulin due to the autoimmune destruction of insulin-producing pancreatic cells. This puts the diabetic patient at risk of developing respiratory, skin, and urinary tract infections.
- Rheumatoid arthritis
Coping with Ineffective Protection
- Patient education. Preventative measures and treatment strategies should be made available to patients, and they should be given space to experience the different transitions that occur during this phase. The support or help of significant other(s), family members, school, the community, and health care providers is also critical for the continuum of care.
- Demonstration of compassionate and high-value care. Patient with chronic diseases commonly complains about human experiences such as anxiety, isolation, and grief. Being an advocate for empathy can help improve the patient’s care experience and alleviate the loneliness, isolation, ill thoughts, and sorrow that come along with the disease’s progression.
- Communicate protocols, policies, guidelines, and care. Positively impacts the patient experience and contributes to meeting the patient’s health literacy needs. Poor communication can result in clinical failures, medication errors, and ineffective treatment.
- Point of care reminders. Provides patients with checklists, allergy wristbands, name charts, operation guidelines, and physician order sheets to facilitate optimum healthcare delivery.
Clinical Management to Prevent or Treat Ineffective Protection
- Nutritional Therapy. The patient’s ability to handle a well-balanced diet is a primary goal. In order to compensate for an increased metabolic rate, the protein level should be between 1 and 2 grams per kilogram of ideal body weight. If the patient has recurring infections, they must receive enough calories to prevent weight loss. Carbohydrate-rich diets provide energy and minimize the use of stored protein. In cases where bile production is inhibited, fat content should be reduced. The patient should avoid caffeine-containing beverages, such as coffee, coke, and tea, to reduce restlessness and sleep disruptions. Discourage the patient to eat spicy or high-fiber foods since these can aggravate an already overactive digestive tract. Severe cases of anorexia and vomiting may necessitate intravenous glucose solutions or enteral nutrition therapy.
- Parenteral nutrition. Provides nutritional support to patients who cannot maintain their oral caloric needs due to a condition or disability (e.g., undergone surgery, cerebral palsy, short bowel syndrome, immobility, etc.). PN allows nutritional deficiencies to be corrected. It also supports immunological function and body mass and minimizes the risk of complications resulting from malnourishment.
- Oxygen support or mechanical ventilation
- Postexposure prophylaxis. The patient should be given postexposure prophylaxis within 24 hours of close contact, needle stick injury, or sexual exposure to an individual with a communicable disease.
- Immunization. The most effective prophylaxis against infectious diseases such as hepatitis A, pneumonia, etc. Patients as young as one year old are eligible to receive the vaccine. Immunization can also be administered to travelers or tourists visiting endemic areas.
Prevention of Ineffective Protection
- Immediate medical attention should be sought if the patient has a pre-existing condition or if clinical symptoms suggest a weakened immune system.
- Advise the patient to modify unhealthy choices such as alcohol abuse, sedentary lifestyle, and unhealthy eating habits.
- The nurse should provide information concerning preventative measures to limit the risk of infection, accident, or injury.
Nursing Considerations on Ineffective Protection
- Identify past and current health information prior to any surgical procedures or medications.
- Patients are at risk of recurrent or opportunistic infections. Observe for signs of infection and bleeding to administer prompt treatment.
- Management of a patient with comorbidities or a disabling condition must incorporate precautions to decrease the risk of infection.
- Employ stringent hand hygiene and an aseptic approach when performing medical procedures such as corticosteroid administration.
- Monitor blood tests and advise the patient to report any anemic symptoms (e.g., fatigue, lethargy)
- Assess for pregnancy prior to drug administration
- Explain that fatigue is a normal physiologic response to medication or therapy.
- Provide supplemental oxygen and transfusion in the presence of hypoxia and low red blood cell (RBC) count.
Ineffective Protection Nursing Diagnosis
Ineffective Protection Nursing Care Plan 1
Nursing Diagnosis: Ineffective Protection related to ventilator dependency, secondary to mechanical ventilation, as evidenced by dyspnea, ineffective cough, restlessness, decreased tidal volume, changes in respiratory rate, and emesis.
Desired Outcome: The patient will be free of or have a decreased risk of injury, as evidenced by proper ventilation settings and the absence of ventilator-associated pneumonia.
|Ineffective Protection Nursing Interventions||Rationale|
|Assess the ventilator settings routinely and alert the respiratory unit of any discrepancies immediately.||Regular evaluation of the ventilator ensures that the patient receives the appropriate mode, rate, positive end respiratory pressure (PEEP), flow rate, tidal volume (TV), and pressure support. Ensure that the alarms on the ventilator are activated, as they warn the caregiver of any ventilation difficulties. A prompt response to an alarm ensures that corrective actions are taken, and enough ventilation is maintained.|
|Assess any alterations in the patient’s level of consciousness (LOC)||Disorientation, restlessness, and agitation are among the first symptoms of hypoxia. Late indications include fatigue, lethargy, and drowsiness.|
|Assess the patient for any indications of pulmonary infection: fever, purulent secretions, cough, dyspnea, and rhonchi. Obtain samples for bacterial cultures and review white blood cell counts.||Patients using ventilators are at increased risk of developing ventilator-associated pneumonia. It also increases the mortality rate and the risk of infections caused by gram-negative bacilli.|
|Evaluate the patient’s respiratory status (e.g., respiratory rate, work of breathing, and rhythm)||Regular evaluation ensures early diagnosis of changes in respiratory status.|
|Monitor for the presence of barotrauma and plateau pressures.||Barotrauma is a typical manifestation of pulmonary tissue damage resulting from pressure differences between an internal, unventilated compartment and an external gas or fluid. Increased plateau pressures also enhance the likelihood and incidence of barotrauma in patients undergoing mechanical ventilation.|
|Elevate the head of the bed (HOB) to 30-45 degrees and allow subglottic secretion drainage unless contraindicated.||Raising the HOB improves lung expansion. Meanwhile, subglottic suctioning eliminates stagnant secretions and minimizes stomach reflux and aspiration.|
|Promote oral hygiene and recommend brushing the teeth with a soft-bristle toothbrush at least 2-3 times a day.||Oral hygiene reduces colonization of bacterial flora, particularly respiratory pathogens that could be aspirated.|
|Institute interventions to prevent ventilator-associated pneumonia.||Prevents nosocomial pneumonia|
Ineffective Protection Nursing Care Plan 2
Nursing Diagnosis: Ineffective Protection related to bone marrow suppression from chemotherapy, secondary to osteosarcoma, as evidenced by thrombocytopenia, hematoma, anemia, amputation, itching and irritation in the stump, and oral discomfort.
Desired Outcome: The patient will not experience any bleeding episodes, and their fever will remain below 37 degrees Celsius.
|Ineffective Protection Nursing Interventions||Rationale|
|Assess the patient for any profuse bleeding and monitor for febrile episodes. Review laboratory findings: platelet count, hematocrit, absolute neutrophil, and white blood cell count.||Active bleeding results in significant decreases in blood profile, necessitating immediate intervention.|
|Check the patient’s dressings for any bleeding and evaluate the stump for redness, drainage, or pain every 2 to 4 hours. Offer routine stump care and cleanse the area thoroughly while rewrapping the site with an elastic bandage.||The presence of bleeding and pain can indicate infection or risk of bleeding at the amputation site.|
|Assist patients with self-care and promote as much independence as possible in conducting activities of daily living (ADL).||Self-care tasks such as eating, oral hygiene, and bathing may boost a patient’s activity level, blood circulation, and muscle strength. It also encourages independence and increases their control over daily personal care needs without causing discomfort or joint damage.|
|Inform the patient to contact their healthcare provider immediately if they have been exposed to a highly contagious or communicable illness. Explain the necessity of immediate medical care if two or more of the following are observed: fever, changes in behavioral reaction, dizziness, exhaustion, headache, changes in skin color, and bleeding.||Patients with osteosarcoma are susceptible to infection due to a compromised immune system. Advising the patient to avoid exposure to individuals who have contracted a disease or have been exposed helps reduce the risk of infection, a precipitating factor in slow wound healing and delayed recovery.|
|Recommend a high protein and calorie diet filled with vitamins and minerals.||Helps speed up the recovery process and prevent weight loss associated with prolonged immobilization.|
|Advise the patient to avoid using a toothbrush with harsh bristles and instead use a toothbrush with soft bristles. Refrain from using rectal thermometers and razors.||Prevents bleeding from the skin and mucous membrane lacerations and abrasions. Since chemotherapy affects platelet and coagulation factors, it raises the risk of bleeding.|
Ineffective Protection Nursing Care Plan 3
Nursing Diagnosis: Ineffective Protection related to abnormal blood profile, secondary to nephroblastoma, as evidenced by altered clotting, impaired immunity, hematuria, and bleeding.
Desired Outcome: The patient will be protected from injury or infection.
|Ineffective Protection Nursing Interventions||Rationale|
|Evaluate the patient’s urine output and take note of any offensive odors.||Indicates the possibility of renal dysfunction or bladder infection|
|Evaluate the presence of excessive bleeding and analyze its laboratory indications (e.g., hemoglobin, platelet count, absolute neutrophil, and hematocrit).||Abnormal blood profiles help identify bleeding caused by bone marrow and chemotherapy-induced immune suppression. In addition, it assists in identifying the need for a rapid transfusion to restore normal blood levels.|
|In the case of severe bleeding, administer blood products as directed. During the transfusion, monitor the patient’s vital signs, and note for the presence of dyspnea, rash, headache, and urticaria.||Increases tissue oxygen supply to compensate for blood loss in the presence of anemia symptoms. Packed red blood cells (RBCs) and a crystalloid solution are frequently provided in combination. Stop the transfusion immediately if the patient exhibits chills, urticaria, a rash, or a headache.|
|Collect urine output for culture analysis.||Immunosuppressive therapy can enhance the risk of infection.|
|Instruct the patient to remain attentive and report any episodes of fever, headache, dizziness, lethargy, pallor, changes in visual acuity, or bleeding.||These parameters indicate an associated abnormal blood profile complication. Prompt patient-reported outcomes may improve treatment decisions and control of the disorder.|
|Monitor changes in blood pressure, pulse rate, and respiration every 2 hours.||Provides vital information about impaired renal function due to the concentration of cellular products in renal tubules from chemotherapy. Moreover, it identifies common surgical complications in primary nephrectomies, such as intestinal obstruction, bleeding, and surgical site infections.|
|Teach the patient about the proper practice of handwashing and have them provide a return demonstration. Ensure the use of appropriate personal protective equipment (PPE), such as masks and gloves, and the practice of hand hygiene before providing treatment or care.||Prevents the transmission of pathogens or infectious agents to an immunocompromised individual|
Ineffective Protection Nursing Care Plan 4
Idiopathic Thrombocytopenic Purpura (ITP)
Nursing Diagnosis: Ineffective Protection related to immune system suppression, secondary to idiopathic thrombocytopenic purpura (ITP), as evidenced by petechiae, purpura, bleeding, and abnormal blood profile.
Desired Outcome: The patient will demonstrate techniques to prevent bleeding and limit the risk of injury.
|Ineffective Protection Nursing Interventions||Rationale|
|Assess the patient for any signs of profuse bleeding and assess the following laboratory tests to detect microscopic bleeding: platelet count, hematocrit, activated partial thromboplastin time (aPTT), bleeding time, prothrombin time (PT), active coagulation time, fibrin degradation products (FDP).||These laboratory tests provide important information about the patient’s coagulation status and cause of bleeding. Prolonged PTT, BT, and normal PT can serve as a differential diagnosis and indicate a deficiency of clotting system factors, necessitating replacement therapy to reduce mortality and its complications (e.g., hypovolemic shock).|
|Inform the patient and caregivers of the preventive measures to prevent trauma, vascular injury, and alterations in clotting mechanisms.||Actions like using extreme care or the use of assistive devices if the patient is unable to ambulate, manage weight, and maintain balance can help prevent falls and keep the patient from hitting against objects or clutter, which could cause severe bleeding.|
|Provide a safe environment for the patient by placing a call light within easy reach, moving them with the utmost caution, and eliminating potential mechanical and physical risks.||Protects the patient from accidents, falls, and injuries|
|Refrain from using restraints||Physically holding or restraining the patient can cause agitation and straining, which can put pressure and result in the formation of purpura.|
|Instruct the patient in performing proper hand hygiene, and have him/her perform a return demonstration. Ensure that the caregiver or healthcare practitioner has washed their hands before and after patient contact.||ITP is typical in immunocompromised patients with chronic infections or severe conditions (e.g., HIV). Handwashing is required before and after medical procedures to reduce the risk of infection and its transmission.|
|Administer blood products as prescribed (e.g., platelet) and monitor for transfusion reactions||Controls severe hemorrhage if increased platelet destruction or dysfunctional formation is the cause of the condition.|
Ineffective Protection Nursing Care Plan 5
Nursing Diagnosis: Ineffective Protection related to abnormal blood profile, secondary to chronic renal failure (CRF), as evidenced by bleeding, hypertension, hematuria, facial mask, guarding behavior, and pain.
Desired Outcome: The patient will not experience bleeding, as evidenced by improvement in laboratory values.
|Ineffective Protection Nursing Interventions||Rationale|
|Assess the patient’s character of fatigue and note its manifestations, such as tachycardia, pallor, dyspnea, and angina.||Acute indicators of weakness or fatigue allow for rapid treatment and dose adjustment of possible anemia due to CRF. Since the production of erythropoietin is impacted, the amount of circulating red blood cells (RBCs) is equally affected. Due to a shortage of RBCs, the blood’s oxygen supply decreases, making it more difficult for the body to maintain homeostasis.|
|Evaluate the patient’s response and capacity to perform activities||Reduced tissue oxygenation caused by anemia increases the risk of accidents and falls.|
|Evaluate the patient’s level of consciousness (LOC) and observe for any indications of hypoxemia.||Anemia caused by CRF impairs mental acuity, orientation, and behavioral responses. A patient’s disruptive conduct may be a result of their disease or the stress connected with its treatment and management; consequently, this can lead to fear and a breakdown in communication, deteriorating their health and reducing their ability to protect themselves from hazards and infections.|
|When administering injections or punctures, use the smallest needle possible and follow up with sustained pressure.||Reduces the likelihood of hematoma formation and bleeding (hemorrhage).|
|Administer oxygen support as prescribed.||It may be necessary to administer oxygen in order to satisfy the body’s metabolic needs and maintain adaptive responses to hypoxemia. Renal tissues necessitate oxygen for perfusion and to sustain renal function.|
|Plan and pace activities that minimize fatigue.||Fatigue can impact and contribute to the risk of external hazards, such as the likelihood of injuries and falls. This can threaten their health and safety, leading to negative patient outcomes. In addition, it impairs cognition, making it more difficult for the nurse to evaluate the patient’s subjective reports of impairment.|
|Administer EPO concentrations, as indicated.||Increases RBC production and maintenance, which alleviates the symptoms of CRF (e.g., dyspnea, exhaustion, itchy skin, nausea, loss of appetite, pain)|
|Instruct the patient to maintain oral hygiene and provide a soft-bristle toothbrush and electric razor.||CRF can cause enamel hypoplasia, dry mouth, alterations in salivary composition, and pale mucosa. These complications can result in bleeding, anemia, and an increased risk of infection.|
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Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
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