Introduction to Nursing Diagnosis – Risk of Pressure Injury in the Child
A nursing diagnosis is an evidence-based bridge between a patient’s problem and definitive medical care. The diagnosis offers research-based explanation for why the patient is experiencing a certain issue or problem and the best treatment options available. The nursing diagnosis “Risk of Pressure Injury in the Child” focuses on the risk of skin breakdown due to an imbalance between tissue pressure and body weight. This diagnosis is applicable to pediatric patients, and is most commonly developed after assessing the child’s positioning, nutrition, and biological needs.
NANDA Nursing Diagnosis Definition
The definition of NANDA nursing diagnosis “Risk of Pressure Injury in the Child” is: “At risk for skin breakdown due to an imbalanced relationship between tissue pressure and body weight, which can result from prolonged immobility or continual application of external forces.”
- Infant reports pain.
- Child expresses discomfort in body part.
- Caregiver reports redness in bony area.
- Redness, warmth, swelling in bony area.
- Lack of sensation/muscle power in area.
- Broken skin identified in area in contact with bed.
- Environmental factors: Unsuitable support surface and inadequate air circulation.
- Behavioral factors: Children engaging in activities that may cause or contribute to tipping or slipping off of support surfaces, such as rolling over, kicking and arching.
- Physiological factors: Immobility caused by decreased muscle tone and strength, obesity, and dehydration.
Children who are prone to pressure injury include those with decreased mobility due to age, developmental level, physical disability, surgery, or illness. Additionally, individuals suffering from malnutrition, anemia, dehydration, edema, diabetes mellitus, paralysis, burns, and plastic surgery are at risk of developing a pressure ulcer.
Tips to reduce the risk of pressure injury in children include maintaining body temperature within normal range, maintaining proper hydration, encouraging ambulation if possible, positioning and turning on a regular basis, and using protective cushions, mattresses, and pads.
Suggestions for Use
When assessing for risk for pressure injury in a child, it is important to consider factors such as skin condition, nutrition status, activity level, and supplies used. In addition, the quality of care provided by the healthcare team should be evaluated to ensure that appropriate measures are implemented to reduce risk of skin breakdown.
Suggested Alternative NANDA Nursing Diagnoses
- Alteration in Comfort: Pain. Pain associated with pressure injury.
- Risk for Fluid Volume Deficit. Risk of dehydration due to inadequate fluid intake.
- Impaired Skin Integrity. Risk of breakdown of the skin due to prolonged contact with a surface.
- Ineffective Airway Clearance. Risk of respiratory distress due to mucus accumulation.
When using the NANDA Nursing Diagnosis “Risk of Pressure Injury in the Child” it is important to consider the context and environment of the patient. Additionally, caregivers should take into account factors that may contribute to or cause the pressure injury and take appropriate steps to reduce the risk of skin breakdown.
List of NOC Results
- Skin Integrity: Preservation of intact skin integrity.
- Pain Control: Effectiveness of strategies to manage pain.
- Body Temperature Regulation: Absence of temperature dysregulation.
- Potential for Risk Reduction: Development of effective strategies to reduce risk.
List of NIC Interventions
- Prevent Skin Breakdown: Implement safety measures to reduce the risk of skin breakdown.
- Risk Identification: Reposition the child every two hours and monitor skin for signs of irritation.
- Skin Care: Provide frequent skin care to assess and treat skin breakdown.
- Mobility: Promote active and passive range of motion activities to maximize patient performance.
NANDA Nursing Diagnosis “Risk of Pressure Injury in the Child” identifies at risk population, associated problems and appropriate preventive measures that should be taken to reduce the risk of skin breakdown. Caregivers must consider physiological, behavioral, and environmental issues that may contribute to the development of pressure injury and implement effective interventions to achieve optimal health results.
- How do you assess for risk of pressure injury? Risk for pressure injury must be assessed by evaluating factors such as skin condition, nutrition status, activity level, and supplies used.
- What are some tips for reducing the risk of pressure injury? Tips for reducing the risk of pressure injury include maintaining body temperature within normal range, maintaining proper hydration, encouraging ambulation if possible, positioning and turning on a regular basis, and using protective cushions, mattresses, and pads.