Introduction For Nursing Diagnosis
Pressure Injury in the Adult is a nursing diagnosis that falls under Skin Integrity and Nutrition from the NANDA International Classification of Nursing Diagnoses. It can be used alongside other nursing interventions to characterize the patient’s skin and neurological integrity to help diagnose and treat a pressure injury.
Pressure Injury In The Adult NANDA Nursing Diagnosis Definition
Pressure Injury In The Adult, as defined by NANDA International, is a disruption in skin integrity and/or underlying soft tissue that results from cumulative or acute pressure from contact with external forces over a short period of time.
Defining Characteristics (Subjectives And Objectives)
- Complaints of sensations of vibration, tenderness, burning and discomfort
- Altered sensation at the site of the pressure injury like tingling, burning, increased sensitivity or numbness
- Edema in the affected area
- Changes in color of the skin including blanching, reddening, mottling or yellowing
- Open wounds that may contain pus, blood or other tissues
- Abnormal skin temperature when compared to tissue surrounding it
- Deformation of tissue due to the force of pressure
- Discoloration of the area
- Firmness, hardness or tenderness in the affected area
- Swelling of the area
All factors related to the development of a pressure injury can be grouped into three categories:
- Systemic conditions (e.g. vascular diseases, endocrine disorders, neoplasms, etc.),
- Neurological conditions (e.g. neuropathies, head trauma, stroke, etc.)
- Local conditions (e.g. insufficient nutrition, abrasion, moisture, etc.)
The relationship between each factor and the development of a pressure injury is unknown but it is believed that any one of these factors can increase the risk of developing a pressure injury.
Patients who are at a higher risk for developing a Pressure Injury in the Adult include those of any age group but especially adults ages 65 and older and those with chronic medical conditions. Those individuals with immobility, incontinence, low blood count, edema, paralysis or extreme skin dryness are most susceptible to developing a pressure injury.
Patients affected by a Pressure Injury in the Adult can experience a variety of associated problems, including pain, infection, uncontrolled bleeding and tissue destruction. These in turn can lead to serious complications such as gangrene or sepsis if not treated correctly.
Suggestions Of Use
Nursing interventions for pressure injuries include regular assessment of the patient’s skin for redness, areas of increased temperature, hardening of the skin and ulcerations.
These should be noted and monitored as they may indicate the beginning stages of a pressure injury. Nurses should also regularly check the pressure points on the patient and provide wound care appropriately.
Suggested Alternative Nanda Diagnosis
If a Pressure Injury in the Adult is associated with any of the following NANDA Diagnoses, the diagnoses may be used in conjunction with a Pressure Injury in the Adult:
- Ineffective Airway Clearance
- Impaired Comfort
- Impaired Skin Integrity
- Acute Pain
- Risk for Infection
When using the NANDA Nursing Diagnosis for Pressure Injury in the Adult, it is important to remember to clearly assess the condition of the patient’s skin and neurological integrity before and during treatment. The nursing interventions developed should include an assessment of the patient’s individual factors and circumstances that may contribute to the development of a pressure injury, such as age, mobility, weight, nutrition history, and concurrent medical conditions.
Nursing Outcomes Classification (NOC) focuses on a more holistic approach to treatment outcomes and effectiveness. The possible NOC outcomes related to a Pressure Injury in the Adult include,
- Skin Integrity
- Skin Mobility
- Tissue Perfusion
- Wound Healing
- Comfort Level
- Pain Control
- Risk Control
Each NOC outcome provides a detailed description of the anticipated result of treatment and should be reviewed to develop a plan for achieving the desired treatments and outcomes.
Nursing Interventions Classification (NIC) focuses service coordination and monitoring to improve the overall patient outcomes. The NIC interventions related to Pressure Injury in the Adult include,
- Wound Care Management
- Skin Surveillance
- Pressure Injury Prevention Strategies
- Tissue Padding
- Allow Patient Comfort Measures
- Provide Personal Hygiene Care
- Nutrition Support
These interventions should be used with other treatments to improve patient outcomes and reduce the risk for further complications.
NANDA Nursing Diagnosis Pressure Injury In The Adult offers a detailed description of an individual patient’s skin integrity, neurological integrity and risk factors contributing to their condition. When used in conjunction with nursing interventions developed through the NOC and NIC, potential risks can be avoided and outstanding complications can be managed.
- What is a Pressure Injury in the Adult?
- A Pressure Injury in the Adult is a disruption in skin integrity caused by external forces over a short period of time.
- What are the defining characteristics of Pressure Injury in the Adult?
- The defining characteristics of Pressure Injury in the Adult are tenderness, burning and discomfort; altered sensation; edema; changes in color of the skin; open wounds; abnormal skin temperature; deformation of tissue; discoloration; firmness, hardness or tenderness; and swelling.
- What are the risk populations for Pressure Injury in the Adult?
- Patients who are at a higher risk for developing a Pressure Injury in the Adult include those of any age group but especially adults ages 65 and older and those with chronic medical conditions.