Introduction to NANDA Nursing Diagnosis: Neonatal Pressure Injury
NANDA nursing diagnoses provide nurses with evidence-based knowledge to assist in evaluating, designing and managing the care of hospitalized patients. The NANDA nursing diagnostic label “Neonatal Pressure Injury” provides a helpful reference when collecting patient data or identifying appropriate care strategies. Understanding the causes and treatments of neonatal pressure injuries is important for nurses to be able to develop effective patient care plans.
NANDA Nursing Diagnosis Definition
The NANDA nursing diagnosis “Neonatal Pressure Injury” refers to a localized irritation or injury caused by excessive sustained pressure on the skin and underlying tissues that can occur in newborns due to decreased mobility, an inadequate assessment of positioning, physical restraint or immobility. This may lead to prolonged exposure to prolonged pressure which can result in skin breakdown.
- Pain with contact
- Insufficient knowledge regarding risks of pressure injuries
- Sleep disturbance
- Changes in skin coloration
- Alteration in sensation or temperature of skin exposed to pressure
- Changes in vital signs
- Redness or edema
- Tense skin
Inadequate sensory and motor development: Neonatal pressure injuries are more likely to occur in newborns who have delayed motor or sensory development due to their immaturity.
Deficient nutrition: Pressure injuries are more likely to occur if the newborn lacks a balanced diet, resulting in poor tissue health and increased susceptibility to injury.
Physiologically immature skin: Neonates have less fat under the skin and more fragile connective tissue, making them more susceptible to developing pressure injuries.
Specific risk factors must be present in order for a pressure injury to develop in a neonate:
- Prolonged immobilization
- Preterm or low birth weight infants
- Small or large body habitus
- Impaired sensory perception
- Friction or shear
- Excessive moisture
Pressure injuries can lead to complications such as infection, sepsis, hypothermia and necrosis of the affected area. Furthermore, pressure injuries can cause discomfort and distress to the infant leading to a heightened level of stress and impaired psychological functioning.
Suggestions for Use
In order to reduce the risk of developing pressure injuries, nurses should assess the situation and take preventative measures such as:
- Regularly change infant’s position on the bed.
- Use a pressure-relieving mattress.
- Provide frequent skin assessments.
- Place pillows or foam wedges between bony prominences and hard surfaces.
- Observe the skin condition before and after dressing changes.
- Consider protective clothing over bony prominences.
- Encourage parent/caregiver to do frequent position changes.
Suggested Alternative NANDA Diagnoses
Alternative diagnostics for neonatal pressure injuries could include:
- Ineffective tissue perfusion
- Skin integrity, risk for impaired
- Imbalanced nutrition, less than body requirements.
- Risk for sepsis
- Risk for hypothermia
- Risk-prone health behavior
It is important to consider the environment of the newborn when assessing for the presence of pressure injuries. Nurses should also monitor for areas of skin breakdown and assess for changes in skin color and temperature.
The outcomes listed in the NOC results included with the “Neonatal Pressure Injury NANDA Diagnosis” are:
- Skin Integrity
- Skin Perfusion
- Tissue Integrity
- Injury Care Management
- Pain Control
- Risk Control
By achieving these outcomes, nurses can improve outcomes for newborns and reduce their risk of developing pressure injuries.
Nurses can use the NIC interventions associated with the “Neonatal Pressure Injury NANDA Diagnosis” to provide better care including:
- Pressure Ulcer Care
- Infection Protection
- Fluid Monitoring
- Nutrition Counseling
- Restorative Care
- Protective Isolation
- Pain Management
Neonatal pressure injuries can have serious consequences if not identified and treated promptly. By familiarizing yourself with NANDA nursing diagnoses such as “Neonatal Pressure Injury”, nurses can be well informed when assessing and providing care to newborns. These guidelines can help to ensure optimal quality of care and reduce the risks of pressure injuries.
- What is a NANDA nursing diagnosis? A NANDA nursing diagnosis is a standardized terminology developed by the North American Nursing Diagnosis Association that assists nurses when collecting patient data and developing patient care plans.
- What are the defining characteristics of a NANDA diagnosis? NANDA diagnoses have both subjective and objective defining characteristics. Subjective characteristics relate to the patient’s experience, such as pain, irritability or lack of knowledge, while objective characteristics are physical signs, such as changes in skin color, temperature or edema.
- What interventions should nurses use for preventing pressure injuries in newborns? Nurses should take preventative measures such as regularly changing infant positions on the bed, using pressure-relieving mattresses, frequent skin assessments, placing pillows or foam wedges between bony prominences and hard surfaces, and encouraging parent/caregiver to do frequent position changes.