The NANDA nursing diagnosis of Risk of Adult Pressure Injury is defined as an individual who is at risk for soft tissue damage due to unrelieved, excessive amounts of pressure. This diagnosis is included in the 2015-2017 NANDA International Nursing Diagnoses: Definitions & Classification.
NANDA Nursing Diagnosis Definition
Risk of Adult Pressure Injury: Vulnerable to impaired skin integrity to unrelieved pressure over prolonged time frame resulting from physical or physiological pressures exceeding hypo-perfusion of tissues.
- Verbalizes concern about risk for pressure injury
- Reports decreased blood flow
- Verbalizes poor skin condition
- Skin discoloration
- Decreased sensation
- Purpura or petechiae
- Decreased peripheral circulation
- Inadequate nutrition
- Lack of sensory perception
- Prominence of bony structure
- Medical equipment or device application
- Inability to reposition independently
- Moisture-associated skin damage
People at greatest risk of adult pressure injury include older adults and people with impaired mobility or consciousness, including those with a history of hypotension, poor nutrition and edema.
Pressure injuries can lead to skin and tissue breakdown, infection, respiratory complications, pain, and ultimately death.
Suggestions for Use
Nurses should assess each person’s risk of developing pressure injury and take steps to prevent them wherever possible. This includes research into safe positioning, good nutrition, and patient education on how to manage their own skin health.
Suggested Alternative NANDA Diagnoses
- Impaired Skin Integrity
- Impaired Physical Mobility
- Risk for Infection
- Risk for Nutrition Imbalance
- Risk for Ineffective Airway Clearance
- Assess the patient’s risk factors for developing pressure injuries.
- Coach the patient on ways to prevent and reduce the chances of pressure injuries.
- Assist the patient with any medical equipment that may be needed to reduce risk.
- Provide patient education on skin health and how to care for it.
- Skin Integrity: The patient’s skin remains unharmed and shows no signs of pressure injuries.
- Risk Control: The patient has taken action to reduce or eliminate risks of developing pressure injuries.
- Mobility Level: The patient is able to move around safely, with or without assistance, to reduce pressure on the skin.
- Self-Care: The patient is able to practice good skin care to reduce the risk of pressure injuries.
- Skin Surveillance: Assessing the patient’s skin for signs of pressure injuries and providing appropriate interventions if necessary.
- Repositioning: Helping the patient to engage in frequent positional changes to decrease pressure on the skin.
- Nutrition Management: Educating the patient on proper nutrition to maintain their skin’s health.
- Skin Care: Providing guidance on proper skin care and hygienic practices to reduce the risk of infection and pressure injuries.
- Positioning Devices: Assisting the patient with devices to relieve pressure on the skin, such as lifts, cushions, mattresses, and foam wedges.
Risk of Adult Pressure Injury is an important NANDA nursing diagnosis to be aware of, especially when working with certain patient populations. With proper assessment, interventions, and patient education, nurses can help reduce the risk of pressure injuries, and improve the quality of life for their patients.
- What is the definition of NANDA Nursing Diagnosis Risk of Adult Pressure Injury?
The NANDA nursing diagnosis of Risk of Adult Pressure Injury is defined as an individual who is at risk for soft tissue damage due to unrelieved, excessive amounts of pressure.
- Which are the Defining Characteristics of Risk of Adult Pressure Injury?
The defining characteristics of Risk of Adult Pressure Injury can be subjective (verbalizes concern about risk for pressure injury; reports decreased blood flow; verbalizes poor skin condition) or objective (skin discoloration; decreased sensation; purpura or petechiae).
- What are the common Related Factors of Risk of Adult Pressure Injury?
Common Related Factors of Risk of Adult Pressure Injury include decreased peripheral circulation; inadequate nutrition; lack of sensory perception; prominence of bony structure; immobility; medical equipment or device application; inability to reposition independently; moisture-associated skin damage; and abrasion.