Introduction for Nursing Diagnosis
Pressure Injury (also known as pressure ulcer or bedsore) is one of the most common medical conditions for people in different ages. Due to immobility and dependency on lifestyle, most often people with bedridden status are susceptible to excessive pressure in certain areas of the body. Children may also show signs of pressure injury due to certain medical condition leading to immobilization. To understand the severity and arrive at a practical nursing diagnosis, it is important to know the definition, risk factors and related problems associated with NANDA nursing diagnosis: Risk Of Pressure Injury In The Child.
NANDA Nursing Diagnosis Definition
NANDA Nursing Diagnosis: Risk Of Pressure Injury In The Child has been defined by NANDA International as a state in which an individual is at risk for developing tissue damage due to intense, prolonged pressure on the skin and underlying tissues. This diagnosis is used to identify children of any age at risk of developing pressure injury.
- Infants & infants report pain or discomfort experienced when there is compression of the skin
- Toddlers verbalize they have difficulty moving while in a reclining position or when being moved when in a chair or bed
- Older children complain of numbness, tightness or loss of sensation in affected areas
- Skin appears pale, reddened, or discolored
- Unusual heat is felt in affected area
- Tenderness, swelling and/or breakdown of skin described upon inspection
- Immobility resulting from functional disability, surgical or medical intervention, or other impairments
- Inadequate positioning of the body
- Lack of knowledge regarding proper body positioning, signs and symptoms of pressure injury and preventive measures
- Prolonged contact between bony prominences and support surfaces
Explanation: Pressure injury in children is most commonly seen in those who are unable to change their body positions due to mobility issues caused by medical or surgical intervention, impairments, or prolonged contact between their bony prominences and the surface they are lying on. Other related factor is lack of knowledge on the part of caregivers on proper body positioning and sign and symptoms of pressure injury and prevention.
- Children with physical disabilities and impaired mobility
- Neonates and premature infants in neonatal intensive care unit (NICU) setting
- Preterm babies
- Low birth-weight infants
- Children at risk of suffering from injury or inflammation due to special medical-surgical condition
- Pediatric patients and ill persons requiring long-term mechanical life support.
Explanation: Children of different ages may be at risk of pressure injury due to their physical disabilities and impaired mobility. Premature or low birth-weight infants are at higher risk of developing this kind of injury in NICU settings. They may also be at risk due to an underlying medical condition. Moreover, pediatric patients on mechanical life support systems and ill persons may also be prone to this type of injury.
- Skin integrity disruption
- Injury risk increase
- Dysfunction of body systems
Explanation: Pressure injury can lead to disruption of skin integrity, infection, cellulites, increase risk of injuries, and even dysfunction in body systems like circulatory system, immune system and nervous system.
Suggestions of Use
- Keep the body in midline position
- Provide adequate support for head and neck
- Keep extremities in neutral position
- Frequently turn the body to prevent pooling of blood in one area
- Use mattress overlays or specialized mattress and pillows
- Assess inflammatory signs
- Check for sensation and movement
Explanation: To reduce the risk of pressure injury in children, it is essential to keep their bodies in a midline position, provide adequate support for head and neck, keep the extremities in a neutral position and frequently turn the body to prevent pooling of blood in an area. Mattress overlays and pillows need to be used as well. Moreover, nurses should assess for inflammatory signs, check for sensation and movement.
Suggested Alternative NANDA Diagnoses
- Ineffective Airway Clearance
- Promotion of Comfort
- Delayed Growth and Development
- Caregiver Role Strain
Explanation: Depending on the patient’s condition, nurses should consider other alternative diagnoses as well such as Ineffective Airway Clearance, Promotion of Comfort, Pain, Delayed Growth and Development, and Caregiver Role Strain.
- Before using any of the above alternative diagnoses, ensure that the patient meets the criteria for that particular diagnosis.
- Be aware of the risk factors for developing pressure injury and plan interventions accordingly.
- Observe and monitor regularly for any changes in the condition of the patient.
- Assess effectiveness of any interventions used.
- Ensure that all pertinent information related to the patient’s condition is documented in the medical record.
- Mobility Level: The patient is able to maintain the mobility level appropriate to his/her age and emotional status.
- Skin Integrity: The patient’s skin remains unaffected by pressure for a given period of time.
- Therapeutic Regimen Management: Family: The family or caregivers demonstrate the use of safety equipment to protect the patient from pressure injury.
- Communication: Receptive: The patient is able to comprehend instructions regarding positioning and motion.
Explanation: The NOC results measure the progress of the patient and help in setting realistic goals. These result categories measure the patient’s mobility level, skin integrity, communication and the family’s ability to carry out therapeutic management.
- Positioning: The nurse will position the patient to achieve maximum comfort, maintain airway patency, maximize circulation, and prevent pressure injury.
- Body Mechanics Teaching: The nurse will teach the patient methods of changing position, techniques for bed mobility, and activities for prevention of pressure injury.
- Pressure Ulcer Prevention: The nurse will assess the patient’s skin for evidence of pressure injury, devise an appropriate prevention plan, and provide necessary resources for the patient.
- Positioning Equipment Selection: The nurse will select appropriate positioning equipment for the patient, such as mattresses and cushions, in order to provide optimum comfort and prevent pressure injury.
Explanation: NIC interventions help in improving the quality of nursing care that can be provided to patients. These include positioning, body mechanics teaching, pressure ulcer prevention, and selection of positioning equipment. All these interventions will help in mitigating the risks associated with pressure injury and improve the patient’s quality of life.
Pressure Injury is a serious medical condition that can affect the quality of life and cause immense discomfort. With the right nursing diagnosis and interventions, it is possible to mitigate the risks associated with this condition. Observing for warning signs and devising appropriate prevention plans are essential for providing the best quality of care for children at risk of developing pressure injury.
- What are the different types of NANDA nursing diagnosis?
NANDA nursing diagnoses refer to a list of standardized nursing diagnoses developed by NANDA International, Inc. Examples include Acute Pain, Risk for Infection, Activity Intolerance, Impaired Mobility, Imbalanced Nutrition and so on.
- What is the definition of NANDA nursing diagnosis: Risk of Pressure Injury in the Child?
NANDA Nursing Diagnosis: Risk Of Pressure Injury In The Child has been defined by NANDA International as a state in which an individual is at risk for developing tissue damage due to intense, prolonged pressure on the skin and underlying tissues.
- Which interventions are used to reduce the risk of pressure injury in children?
To reduce the risk of pressure injury in children, it is essential to keep their bodies in a midline position, provide adequate support for head and neck, keep the extremities in a neutral position and frequently turn the body to prevent pooling of blood in an area. Mattress overlays and pillows need to be used as well. Moreover, nurses should assess for inflammatory signs, check for sensation and movement.