Adult pressure injury

NANDA Nursing Diagnose - Adult pressure injury

  • Code: 00312
  • Domain: Domain 11 - Safety - protection
  • Class: Class 2 - Physical injury
  • Status: Current diagnoses

The NANDA-I diagnosis 'Adult pressure injury' holds significant relevance in nursing practice, as it addresses a critical aspect of patient care that can greatly impact recovery outcomes. Understanding this diagnosis is vital for healthcare professionals, particularly in environments where patients are at heightened risk, such as intensive care units, rehabilitation centers, and long-term care facilities. As the incidence of pressure injuries continues to rise, recognizing the importance of proactive assessment and prevention strategies becomes increasingly essential for delivering high-quality nursing care.

This blog post explores the NANDA-I diagnosis 'Adult pressure injury' in depth, focusing on its definition and key characteristics. It will cover the critical aspects of this diagnosis, including the various clinical manifestations and related factors that contribute to the development of pressure injuries. By providing a comprehensive overview, the post aims to enhance understanding of risk populations and associated conditions, ultimately equipping nurses with the knowledge needed to prevent and manage this common yet serious health concern.

Definition of the NANDA-I Diagnosis

The NANDA-I diagnosis of 'Adult pressure injury' refers to a localized area of damage to the skin and/or underlying tissues that occurs as a direct result of sustained pressure, or a combination of pressure and shear forces, typically affecting individuals over the age of 18. This condition can manifest in various forms, ranging from superficial skin alterations to deep tissue injuries, and can occur in any area of the body that experiences prolonged pressure, particularly over bony prominences. The classification includes stages of injury severity, which may present as erythema, blood-filled blisters, or full thickness tissue loss, potentially exposing bone, muscle, or tendons. Contributing factors to the development of pressure injuries include external elements like friction, moisture, and surface characteristics, as well as internal factors such as immobility, malnutrition, and underlying health conditions. Recognizing at-risk populations, such as older adults, individuals in intensive care, and those with mobility impairments, is critical in preventing and managing this significant health issue, which can lead to pain and further complications if left unaddressed.

Defining Characteristics of the NANDA-I Diagnosis

The NANDA-I diagnosis "Adult pressure injury" is identified by its defining characteristics. These are explained below:

  • Ampolla llena de sangre

    This characteristic indicates the formation of blood-filled blisters on the skin. The presence of these blisters typically signifies localized tissue ischemia, suggesting that the skin and underlying structures are under significant stress. The presence of blood in the blister indicates that the microvascular circulation has been compromised, which is a hallmark of pressure injury development. Clinically, it is essential to identify these blisters early as they can rupture and lead to further tissue damage or infection, worsening the overall injury.

  • Eritema

    Erythema, or redness of the skin, is often the first clinical sign of a developing pressure injury. This manifestation occurs due to increased blood flow to the affected area in response to tissue injury or inflammation. Erythema may be a transient response to pressure, and its persistence can indicate that damage to the dermal layers has occurred. Clinically, assessing erythema involves checking the blanching response; if the redness does not disappear upon pressure, it suggests a more severe degree of tissue compromise.

  • Pérdida de tejido de espesor total

    This characteristic represents full-thickness loss of skin, where both the epidermis and dermis are extensively damaged or destroyed. This is a critical sign of advanced pressure injury and signifies that deeper structures, including subcutaneous fat, may also be involved. Full-thickness loss is clinically significant as it greatly increases the risk of infection, complications, and prolonged healing times, necessitating surgical intervention in many cases.

  • Pérdida de tejido de espesor total con hueso expuesto

    This is a severe manifestation where bone is directly visible due to the destruction of all skin layers and soft tissues. This finding indicates a critical level of tissue loss and ongoing necrosis, confirming a stage 4 pressure injury. The clinical implications of bone exposure include a high risk of osteomyelitis, delayed wound healing, and necessitating aggressive management strategies, including possible surgical debridement.

  • Pérdida de tejido de espesor total con músculo expuesto

    The exposure of muscle tissue signifies an even more profound degree of injury and is indicative of a stage 3 or 4 pressure ulcer. Muscle exposure not only complicates treatment due to the heightened risk of infection but also reflects significant underlying tissue loss. Clinically, muscle exposure may necessitate advanced wound care techniques and can lead to functional impairment depending on the muscle's location and role.

  • Pérdida de tejido de espesor total con tendón expuesto

    This defining characteristic suggests that tendons are visible due to extensive tissue loss. The clinical significance lies in the urgency for intervention; exposed tendons are at a high risk of infection and necrosis, which can threaten limb viability. Moreover, the presence of exposed tendons can lead to significant functional deficits if not addressed promptly.

  • Calor localizado en relación con el tejido circundante

    Localized warmth in the area of a pressure injury suggests inflammatory processes and infection. The increase in temperature is an indication of increased blood flow, which occurs as the body attempts to heal the damaged tissue. Clinically, this can serve as a warning signal of possible infection or complications that may necessitate aggressive intervention, such as antibiotics or even debridement.

  • Dolor en puntos de presión

    Pain or tenderness in areas under pressure can indicate impending tissue damage. Patients often experience discomfort in areas that have prolonged exposure to pressure, which can serve as an early warning sign. Clinically, it's critical to assess pain levels as they can guide the clinician to evaluate the adequacy of the intervention and the need for repositioning or other modalities to enhance patient comfort and prevent further injury.

  • Pérdida parcial del grosor de la dermis

    This characteristic indicates superficial tissue damage and may present as a shallow open sore. Clinically, this stage is often reversible with proper interventions, such as regular repositioning and pressure relief. However, recognizing partial-thickness loss is vital, as it necessitates timely intervention to prevent progression to more severe injuries.

  • Área localizada morada de piel intacta descolorida

    A localized area of intact skin that appears purple or maroon may indicate a deep tissue injury, suggesting underlying damage despite the skin's surface being intact. Clinically, recognizing this sign is crucial, as it highlights the need for monitoring and early interventions to prevent further tissue breakdown.

  • Úlcera cubierta por escara

    This denotes a pressure injury that is covered with necrotic tissue or eschar, making assessment challenging. Clinically, it is vital to evaluate the underlying tissue health and whether the wound is infected or healing. Proper management may require debridement to facilitate healing and assess the depth of the wound.

  • Úlcera cubierta por membrana necrótica

    The presence of necrotic tissue over a wound complicates the healing process, as it can harbor bacteria and inhibit granulation tissue formation. Clinically, understanding this characteristic is essential for appropriate treatment planning, which may include the need for surgical intervention to remove necrotic tissue and promote healing.

Related Factors (Etiology) of the NANDA-I Diagnosis

The etiology of "Adult pressure injury" is explored through its related factors. These are explained below:

  • External Factors
    • Microclima alterado entre la piel y la superficie de apoyo - Conditions such as excess moisture or elevated temperature between the skin and support surfaces can lead to skin maceration, thereby degrading the skin's barrier function. This increases susceptibility to pressure injuries, as the skin becomes fragile and less resilient against sustained pressure.
    • Acceso inadecuado a equipos apropiados - A lack of appropriate equipment, such as specialized mattresses, cushions, or mobility aids, diminishes a caregiver's ability to effectively reposition patients or relieve pressure, which is critical in preventing pressure injuries.
    • Acceso inadecuado a servicios de salud apropiados - Limited access to healthcare services can prevent timely assessments and interventions, leading to unmanaged risk factors for pressure injuries, particularly in high-risk populations.
    • Disponibilidad inadecuada de equipos para individuos con obesidad - The absence of resources suited for the unique needs of obese patients increases their vulnerability to pressure injuries due to inadequate support and pressure relief.
    • Conocimiento inadecuado de las estrategias de prevención de lesiones por presión por parte del cuidador - Insufficient training on preventive measures can lead to neglectful practices in patient care, thereby increasing the likelihood of pressure injuries developing.
    • Nivel de humedad de la piel inapropiado - Excessive moisture can lead to skin breakdown and lessen resilience, while overly dry skin can crack and become an entry point for infection, both of which are critical factors in the development of pressure injuries.
    • Aumento de la magnitud de la carga mecánica - Excessive mechanical loads can compromise tissue perfusion, especially in vulnerable areas, leading to ischemia and subsequent tissue necrosis if not managed through regular repositioning and support surface adjustments.
    • Presión sobre prominencias óseas - Bony prominences are naturally vulnerable to pressure due to limited soft tissue cushioning. Sustained pressure in these areas can lead to localized ischemia, eventually resulting in tissue death.
    • Fuerzas de cizallamiento - Shear forces occur when different layers of tissue move in different directions. This can stretch and tear blood vessels, disrupting blood flow and contributing to the development of pressure injuries.
    • Fricción en la superficie - Friction can strip the skin's external layer, making it more prone to breakdown when combined with shear forces and pressure, escalating the risk for injury.
    • Carga mecánica sostenida - Keeping burdensome weight on a singular surface for prolonged periods can exacerbate ischemic conditions in tissues, necessitating diligent monitoring and management to minimize pressure injury risk.
    • Uso de sábanas con propiedades inadecuadas para el manejo de la humedad - Bed linens that do not regulate moisture effectively can create a warm and damp environment, detrimental to skin integrity and a significant risk factor for pressure injuries.
  • Internal Factors
    • Actividad física disminuida - Reduced mobility limits a patient’s ability to shift weight and relieve pressure, creating an environment conducive to pressure injury formation.
    • Piel seca - Dehydrated skin is more vulnerable to breakdown and less elastic, making it susceptible to pressure-related damage when compressed against surfaces for prolonged periods.
    • Hipertermia - Elevated body temperature can accelerate metabolism and tissue turnover but also increases the risk of tissue damage, particularly in conjunction with pressure and other risk factors.
    • Movilidad física comprometida - Restrictions in movement prolong the application of pressure to tissue, increasing the likelihood of developing pressure injuries, especially in individuals with significant mobility impairment.
    • Adherencia inadecuada al régimen de tratamiento de incontinencia - Poor adherence to incontinence management can lead to excessive moisture and skin breakdown, elevating the risk of pressure injuries, especially in patients confined to bed or wheelchair-bound individuals.
    • Adherencia inadecuada al plan de prevención de lesiones por presión - Failure to follow preventive strategies can result in unmitigated pressure on vulnerable areas, leading to an increased prevalence of pressure injuries.
    • Volumen de líquidos inadecuado - Insufficient hydration can impair skin integrity and wound healing, leading to heightened risks of pressure injuries due to compromised tissue resilience.
    • Conocimiento inadecuado de las estrategias de prevención de lesiones por presión - A lack of understanding of pressure injury prevention protocols can hinder a caregiver's capability to implement effective strategies, putting patients at risk.
    • Malnutrición proteico-energética - Nutritional deficiencies can impede wound healing and overall skin health, significantly increasing susceptibility to pressure injuries, especially in undernourished populations.
    • Abuso de sustancias - Substance use disorders can complicate health management and increase risk factors for pressure injuries due to impaired health status and increased likelihood of neglect in care.
    • Uso de tabaco - Smoking negatively impacts circulation and oxygen delivery to tissues, thereby increasing the risk of pressure injuries as the skin and tissues become less resilient to stress.

At-Risk Population for the NANDA-I Diagnosis

Certain groups are more susceptible to "Adult pressure injury". These are explained below:

  • Individuals in Healthcare Settings
    • Individuals in Nursing Homes: Residents in nursing homes often have limited mobility due to age, chronic illness, or cognitive impairments such as dementia. The continuous pressure from immobility on specific body areas, combined with decreased sensory perception, makes them particularly vulnerable to pressure injuries. Environmental factors, including the quality of mattresses and positioning protocols, further amplify their risk.
    • Individuals in Intensive Care Units (ICUs): Patients in ICUs are typically suffering from severe, life-threatening conditions that necessitate prolonged bed rest. The use of sedatives or neuromuscular blockers can significantly inhibit their ability to shift positions and maintain adequate blood flow to pressure-prone areas. Additionally, fragile skin integrity and the presence of medical devices, like catheters and ventilators, increase susceptibility to injury.
    • Individuals in Palliative Care: This population often experiences significant health complications that limit mobility, combined with advancing age or multifaceted comorbidities. The focus on comfort rather than curative measures might lead to neglect in proper repositioning and skin assessments, which are crucial in preventing pressure injuries.
    • Individuals in Rehabilitation: While undergoing rehabilitation, patients often have temporary immobility issues due to surgeries, fractures, or strokes. Their compromised mobility, alongside increased muscle tone or spasticity, may prevent them from shifting position frequently enough to relieve pressure, leading to a higher risk of developing pressure injuries.
  • Individuals Transitioning Between Care Settings
    • Individuals in Transit: When patients are moving between different clinical settings, they may receive suboptimal care due to a lack of established routines for pressure injury prevention. Changes in the standards of care, unfamiliar protocols, and increased anxiety during transitions can lead to lapses in positioning, assessment, or nutrition — critical factors in pressure injury prevalence.
    • Individuals Receiving Home Care: This demographic often relies heavily on caregivers who may lack adequate training in pressure injury prevention. Caregivers’ understanding of warning signs and proper repositioning techniques is crucial. Moreover, inadequate resources and home environments may not support the same level of preventive strategies available in institutional settings.
  • Individuals with Specific Health Profiles
    • Individuals with ASA Class 3: Those classified by the American Society of Anesthesiologists (ASA) as Class 3 have severe systemic disease that limits their mobility. This condition not only hinders their capacity to reposition themselves but also increases the likelihood of complications, such as circulatory problems or neuropathies, further heightening the risk for pressure injuries.
    • Individuals with Abnormal BMI: Both obesity and underweight statuses are critical risk factors for pressure injuries. Individuals with a Body Mass Index (BMI) above the normal range may have impaired mobility, increased tissue tension, and decreased blood flow due to fat deposits. Conversely, those with a low BMI often exhibit skin fragility and poor nutritional status, both of which contribute significantly to skin breakdown.
    • Individuals with a History of Pressure Injuries: Previous occurrences of pressure injuries are one of the strongest predictors for future events. Patients with a history are often subjected to similar risk factors that led to prior injuries, including immobility and chronic illnesses, thus necessitating a heightened focus on preventive measures.
    • Individuals with Physical Disabilities: Physical disabilities can lead to immobility or limited movement, making it challenging to reposition themselves effectively. These individuals may also experience other complications related to their condition, such as skin changes or reduced sensation in pressure-prone areas, increasing their risk of pressure injuries.
    • Older Adults: Aging is associated with various physiological changes, such as reduced skin elasticity, chronic medical conditions, and medications that affect blood flow. These factors together increase the vulnerability of older adults to pressure injuries, making vigilant assessments and preventive strategies essential in this population.

Associated Conditions for the NANDA-I Diagnosis

The diagnosis "Adult pressure injury" can coexist with other conditions. These are explained below:

  • Anemia - Anemia leads to decreased oxygenation of tissues, resulting in weakness and fatigue. This diminished physical strength can make it challenging for individuals to shift their positions, thus increasing the duration of pressure applied to specific skin areas. Prolonged pressure is a crucial factor in the development of pressure injuries, making it important to assess hemoglobin levels and the patient's overall nutritional status.
  • Cardiovascular Diseases - These conditions impair circulation, limiting blood flow to the skin. Reduced perfusion can lead to nutrient deprivation and the inability of tissues to withstand pressure, thereby raising the risk for pressure injuries. Care plans must incorporate monitoring cardiovascular health to optimize tissue perfusion and minimize injury risk.
  • Central Nervous System Disorders - Neurological conditions can compromise sensory perception and movement, pivotal factors in preventing pressure injuries. Individuals may lack awareness of pressure on certain body areas and may fail to reposition themselves. This necessitates careful monitoring and interventions aimed at maintaining skin integrity.
  • Chronic Neurological Diseases - Similar to central nervous system disorders, chronic neurological diseases such as multiple sclerosis or Parkinson's can lead to sustained immobility or altered sensation. This increases the risk of developing pressure injuries and requires a proactive approach to patient positioning and skin assessments.
  • Critical Illness - Patients in critical condition often require extensive bed rest and may have multiple comorbidities that complicate their clinical picture. They are at heightened risk of developing pressure injuries due to prolonged immobility, diminished oxygenation, and the potential for skin integrity issues. Comprehensive care plans must address early assessment and preventative strategies against pressure injuries.
  • Hypoalbuminemia - Low serum albumin levels can indicate inadequate nutritional intake and protein malnutrition, resulting in poor skin integrity and slower wound healing. As hypoalbuminemia impairs tissue repair mechanisms, patients are at an increased risk to develop pressure injuries, requiring dietary interventions and nutritional support.
  • Decreased Tissue Oxygenation - Conditions that decrease tissue oxygenation contribute directly to the risk of pressure injuries. Insufficient oxygen supply to tissues affects cellular metabolism and can lead to tissue necrosis. Assessing and enhancing oxygen delivery to at-risk tissues is vital in preventing injuries.
  • Decreased Tissue Perfusion - Issues such as vascular disease may impede blood supply to critical areas, increasing the risk for ischemic pressure injuries. Care strategies should involve regular monitoring and therapeutic interventions aimed at improving circulation and ensuring adequate tissue perfusion.
  • Diabetes Mellitus - Diabetes can lead to neuropathy, which diminishes sensation and the ability to perceive pressure. Additionally, metabolic changes in diabetes can result in delayed wound healing. Proper diabetes management, regular foot care, and comprehensive skin assessments are critical components of care to prevent pressure injuries in diabetic patients.
  • Edema - Swelling from edema can increase local pressure on skin surfaces, raising the risk for injuries. This is particularly pertinent in immobile patients. Addressing the underlying cause of edema and implementing strategies for skin care can help mitigate this risk.
  • Increased C-reactive Protein (CRP) - Elevated levels of CRP indicate systemic inflammation and may suggest heightened injury risk. Monitoring CRP can help assess the inflammatory state and guide timely interventions to prevent pressure injuries.
  • Hemodynamic Instability - Patients with unstable hemodynamics face challenges in maintaining adequate circulation to vital organs, including the skin. This instability increases the risk of pressure injuries, and clinical attention is required to stabilize the patient's condition.
  • Hip Fracture - A hip fracture typically results in reduced mobility and often necessitates surgery or prolonged bed rest. Patients may find it difficult to adjust their positions, significantly increasing the risk of pressure injuries. Comprehensive mobility assistance and skin care protocols are essential in recovery.
  • Immobility - Prolonged periods without movement contribute to the development of pressure injuries by maintaining pressure on specific body areas. Active and passive mobilization strategies should be incorporated in care plans to mitigate this risk.
  • Compromised Circulation - Insufficient blood flow places tissues at risk due to decreased nutrient and oxygen delivery, making it essential to assess vascular health regularly, especially in at-risk populations.
  • Intellectual Disability - Patients with intellectual disabilities may struggle to communicate discomfort or recognize the need for repositioning, increasing their susceptibility to pressure injuries. Tailored care strategies must incorporate suitable communication tools and regular skin assessments.
  • Medical Devices - Devices such as catheters and drains can cause localized pressure, contributing to injury development. Care protocols must include strategies to minimize pressure and monitor skin integrity around device sites.
  • Peripheral Neuropathy - This condition diminishes the patient's ability to feel pain or pressure, which increases the likelihood of pressure injuries going unnoticed. Regular skin checks and appropriate padding strategies are critical for at-risk individuals.
  • Pharmaceutical Preparations - Some medications, particularly corticosteroids or anticoagulants, may have side effects that compromise skin integrity. Medication review and alternative treatments may be necessary to minimize risks associated with skin integrity.
  • Physical Trauma - Previous skin injuries can predispose areas to further damage, necessitating careful assessment and monitoring of any historical wounds or existing skin conditions to prevent recurrences.
  • Prolonged Surgical Procedure Duration - Extended periods in a surgical position can result in significant tissue pressure, necessitating careful monitoring of patient positioning and tissue health during postoperative recovery.
  • Sensory Disorders - Disorders that impact sensory perception can leave patients unaware of excessive pressure, which directly contributes to injury risk. It is critical to integrate regular assessments and educational strategies tailored to individual patient needs.
  • Spinal Cord Injuries - These injuries can affect bodily response mechanisms and mobility, creating unique challenges in pressure injury prevention. Individualized care plans must be developed to account for these limitations and enhance preventive measures for skin integrity.

NOC Objectives / Expected Outcomes

For the NANDA-I diagnosis "Adult pressure injury", the following expected outcomes (NOC) are proposed to guide the evaluation of the effectiveness of nursing interventions. These objectives focus on improving the patient's status in relation to the manifestations and etiological factors of the diagnosis:

  • Skin Integrity
    This outcome is crucial for measuring the restoration and maintenance of skin integrity, which is directly impacted by pressure injuries. Improvement in this area indicates that interventions related to pressure relief and skin care are effective, signifying healing of existing injuries and prevention of new ones.
  • Thermal Comfort
    Maintaining an appropriate temperature for the patient is important as it affects skin condition and healing. This outcome helps in assessing whether the interventions are effective in keeping the skin at a temperature that minimizes risk factors for pressure injury, such as excessive moisture or dryness.
  • Mobility
    Enhancing mobility is critical in the prevention and treatment of pressure injuries. This outcome measures the patient's ability to move and change positions independently, which is essential to relieve pressure on susceptible areas and prevent further injury.
  • Knowledge: Pressure Injury Prevention
    This outcome evaluates the patient's understanding of pressure injury prevention. Educating the patient and caregivers about risk factors and preventive measures is vital for long-term management and reducing recurrence, making this a key expected outcome in the care plan.

NIC Interventions / Nursing Care Plan

To address the NANDA-I diagnosis "Adult pressure injury" and achieve the proposed NOC objectives, the following nursing interventions (NIC) are suggested. These interventions are designed to treat the etiological factors and manifestations of the diagnosis:

  • Pressure Injury Prevention
    This intervention involves implementing strategies to redistribute pressure on sensitive areas of the skin. Caregivers are taught to reposition patients at regular intervals and utilize specialized mattresses or cushions. This helps to prevent the formation of new pressure injuries while promoting skin integrity.
  • Wound Care
    This consists of cleaning the pressure injury and applying appropriate dressings based on the wound's characteristics. Proper wound care facilitates healing by maintaining a moist environment and preventing infection, thus directly addressing the integrity of the skin and underlying tissues.
  • Skin Care Management
    This intervention focuses on maintaining skin cleanliness and hydration, including the use of barrier creams to protect at-risk areas. By ensuring the skin is well-nourished and protected from moisture and friction, this intervention helps to safeguard against pressure injury development.
  • Nutritional Support
    Implementing a nutritional plan that includes adequate protein and caloric intake supports skin health and wound healing. This intervention is essential for providing the nutrients necessary for cell regeneration and repair and addressing any nutritional deficiencies that may impede recovery.
  • Patient and Family Education
    Educating both the patient and their caregivers about the risk factors, prevention strategies, and overall management of pressure injuries empowers them to participate actively in care. This intervention fosters compliance and encourages proactive measures, significantly improving patient outcomes.

Detailed Nursing Activities

The NIC interventions for the NANDA-I diagnosis "Adult pressure injury" are composed of specific activities that nursing staff carry out to provide effective care. Below, examples of activities for the key identified interventions are detailed:

For the NIC Intervention: Pressure Injury Prevention

  • Reposition the patient every two hours to alleviate pressure on vulnerable skin areas and promote circulation.
  • Assess and document skin condition daily, focusing on areas over bony prominences to identify any early signs of breakdown.
  • Utilize pressure-relieving devices such as specialized mattresses or cushions to distribute body weight evenly.
  • Educate the patient and caregivers about the importance of mobilization and encourage participation in physical therapy sessions.

For the NIC Intervention: Wound Care

  • Clean the pressure injury wound using a sterile saline solution to remove debris and reduce the risk of infection.
  • Apply the appropriate dressing as per the wound assessment (e.g., hydrocolloid, foam), ensuring it is secure and moisture-retentive.
  • Monitor the wound for signs of infection (e.g., increased redness, heat, purulent drainage) and notify the healthcare provider as necessary.
  • Document the wound size, appearance, and patient's pain level in the electronic health record for ongoing assessments.

For the NIC Intervention: Nutritional Support

  • Assess the patient's nutritional status, including weight, dietary habits, and laboratory values, to determine if a specialized diet is needed.
  • Collaborate with a dietitian to develop a nutrition plan rich in protein and calories tailored to the patient's needs for wound healing.
  • Encourage the intake of nutrient-dense foods and oral supplements, providing education about their importance for skin integrity.
  • Monitor the patient's fluid intake and output, adjusting hydration plans as necessary to maintain optimal skin health.

Practical Tips and Advice

To more effectively manage the NANDA-I diagnosis "Adult pressure injury" and improve well-being, the following suggestions and tips are offered for patients and their families:

  • Regularly Change Positions

    Shift your position every 2 hours to relieve pressure on vulnerable areas. This practice helps prevent additional damage to the skin and promotes circulation.

  • Use Supportive Cushions

    Invest in specialized cushions or mattresses that distribute weight evenly. These tools can significantly reduce pressure on high-risk areas like the back and heels.

  • Maintain Skin Hygiene

    Keep the skin clean and dry to prevent infections. Regular bathing and moisturizing can help maintain skin integrity and support healing.

  • Nutrition Matters

    Consuming a balanced diet rich in proteins, vitamins, and minerals supports the body’s healing processes. Include foods that promote skin health, such as fruits, vegetables, and lean proteins.

  • Stay Hydrated

    Drink plenty of fluids to keep your skin hydrated and improve overall health. Adequate hydration aids in skin elasticity and repair.

  • Inspect Skin Daily

    Regularly check your skin for any signs of pressure injuries, such as redness or swelling. Early detection is key to effective treatment and prevention of complications.

  • Educate Caregivers

    Ensure that anyone involved in your care understands how to prevent pressure injuries and recognize early symptoms. Knowledgeable caregivers can make a significant difference in your health outcomes.

Practical Example / Illustrative Case Study

To illustrate how the NANDA-I diagnosis "Adult pressure injury" is applied in clinical practice and how it is addressed, let's consider the following case:

Patient Presentation and Clinical Context

A 68-year-old female patient, Mrs. Smith, was admitted to the hospital following hip surgery due to a fall. She has a history of type 2 diabetes and limited mobility. During the admission assessment, the nursing team noted the importance of evaluating her skin condition due to her increased risk for pressure injuries.

Nursing Assessment

During the assessment, the following significant data were collected:

  • Key Subjective Datum: Patient reports "I can’t move much," indicating limited mobility and potential risk for pressure injury development.
  • Key Objective Datum 1: Skin assessment reveals a Stage II pressure injury on the sacrum, characterized by partial-thickness loss of skin.
  • Key Objective Datum 2: Observed redness and localized warmth on bony prominences, particularly around the heels and elbows.
  • Key Objective Datum 3: Braden Scale score of 12, indicating a high risk for pressure ulcer development.
  • Key Objective Datum 4: Patient's nutritional intake is poor, with a dietary assessment identifying inadequate protein and calorie consumption.

Analysis and Formulation of the NANDA-I Nursing Diagnosis

The analysis of the assessment data leads to the identification of the following nursing diagnosis: Adult pressure injury. This conclusion is based on the presence of a Stage II pressure injury, reduced mobility, poor nutritional status, and the Braden Scale score of 12 that indicates high risk factors for pressure injury development. These findings align with the defining characteristics of pressure injuries, necessitating a focused care plan.

Proposed Care Plan (Key Objectives and Interventions)

The care plan will focus on addressing the "Adult pressure injury" diagnosis with the following priority elements:

Objectives (Suggested NOCs)

  • Maintain skin integrity and promote healing of existing pressure injuries.
  • Enhance nutritional status to support skin health and wound healing.

Interventions (Suggested NICs)

  • Pressure Injury Management:
    • Perform routine skin assessments every shift to monitor healing and prevent deterioration.
    • Implement turning and repositioning schedule for the patient every 2 hours to relieve pressure.
  • Nutritional Support:
    • Consult with a dietitian to develop a high-protein and calorie-rich meal plan.
    • Encourage intake of nutritional supplements as recommended to optimize recovery.

Progress and Expected Outcomes

With the implementation of the proposed interventions, it is expected that the patient will show signs of improvement in the healing of the pressure injury, including reduction in size and pain, as well as an overall improvement in nutritional status. Continuous monitoring will allow evaluation of the plan's effectiveness, ensuring appropriate adjustments are made to enhance patient outcomes.

Frequently Asked Questions (FAQ)

Below are answers to some frequently asked questions about the NANDA-I diagnosis "Adult pressure injury":

What is an adult pressure injury?

An adult pressure injury, also known as a pressure ulcer or bedsore, is damage to the skin and underlying tissue that occurs due to prolonged pressure on the skin. This can happen when a person is immobile or seated for long periods of time.

Who is at risk for developing a pressure injury?

Individuals at higher risk include those who are elderly, have limited mobility, have poor nutrition, or have chronic conditions such as diabetes. Anyone who stays in one position for an extended time is also at risk.

How can pressure injuries be prevented?

Preventing pressure injuries involves regularly changing positions, using pressure-relief devices (like special mattresses or cushions), maintaining good skin hygiene, and ensuring proper nutrition to promote skin health.

How are pressure injuries treated?

Treatment of pressure injuries includes relieving pressure, cleaning the wound, using appropriate dressings, and sometimes removing damaged tissue. Pain management and nutritional support are also important in the healing process.

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