Child pressure injury – NANDA Diagnoses

NANDA Nursing Diagnose - Child pressure injury

Código del diagnóstico: 00313
Dominio del diagnóstico: Domain 11 - Safety - protection
Clase del diagnóstico: Class 2 - Physical injury

Understanding the NANDA-I diagnosis 'Child pressure injury' is crucial for nurses and healthcare professionals who care for pediatric patients. Pressure injuries pose significant risks to children, particularly those in vulnerable healthcare settings such as intensive care units and long-term care facilities. By recognizing and effectively managing these injuries, we can greatly enhance patient outcomes, ensuring that our youngest and most susceptible patients receive the highest standard of care. This diagnosis not only reflects immediate clinical challenges but also highlights the need for prevention strategies and caregiver education to mitigate risks in at-risk populations.

This post will delve into the nuances of the NANDA-I diagnosis 'Child pressure injury', beginning with a comprehensive definition that outlines the complexity of these localized injuries. Key aspects, including defining characteristics like erythema, tissue loss, and underlying factors that contribute to their development, will be thoroughly examined. A complete overview will also address related factors, the populations at risk, and associated conditions, providing an exhaustive resource for nursing practitioners seeking to improve their understanding and management of this critical diagnosis.

Definition of the NANDA-I Diagnosis

The NANDA-I diagnosis of 'Child pressure injury' refers to a specific type of localized damage that occurs to the skin and/or underlying tissue in individuals aged from 29 days to 18 years, primarily resulting from sustained pressure or a combination of pressure and shear forces acting on the skin. This condition is particularly concerning in pediatric populations who may have limited mobility or impaired sensory perception, making them more susceptible to the development of these injuries. The injury can manifest in various stages, from superficial areas of erythema and partial thickness skin loss to more severe forms involving full thickness tissue loss that may expose underlying structures such as muscle or bone. Several intrinsic and extrinsic factors contribute to the development of child pressure injuries, including inadequate caregiver knowledge about prevention strategies, altered moisture levels in the skin, use of inappropriate surfaces or supports, and underlying health issues such as malnutrition or immobility. Consequently, understanding and identifying the risk factors and characteristics associated with this diagnosis enable healthcare professionals to implement effective prevention and management strategies tailored to the unique needs of the child, ultimately enhancing their care and promoting healing.

Defining Characteristics of the NANDA-I Diagnosis

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

Subjective Characteristics
- Ampolla llena de sangre: The presence of a blood-filled blister indicates significant underlying tissue damage, revealing a risk for deeper pressure injuries. In children, this can signify compromised vascular integrity and necessitates careful monitoring to prevent further deterioration. Clinically, the identification of such blisters prompts immediate intervention to manage potential infection and provide the appropriate wound care.
- Eritema: The redness of the skin, which indicates inflammation or irritation, is often an early sign of pressure injury. In pediatric patients with sensitive skin, even slight erythema can signify the beginning stages of pressure injury. Clinically, assessing the blanching response and monitoring erythema for duration is critical, as it can guide the timing of preventive measures, including repositioning and skin protection strategies.
- Dolor en puntos de presión: Complaints of pain in areas subjected to pressure are crucial for diagnosing pressure injuries in children who may not articulate their sensations effectively. The identification of pain not only supports the diagnosis but also emphasizes the need for immediate action to relieve pressure and assess the affected areas. Pain assessment can guide clinical decision-making and direct focused interventions to alleviate discomfort.
Objective Characteristics
- Pérdida de tejido de espesor total: This characteristic reflects the destruction of all skin layers, jeopardizing the integrity of underlying structures, including muscles and bones. The presence of such a condition demands immediate clinical attention, as full-thickness injuries are prone to complications such as infection and delayed healing. Clinically, it necessitates a thorough examination to evaluate the extent of injury and to enact a comprehensive treatment plan aimed at promoting healing.
- Calor localizado en relación con el tejido circundante: Elevated localized temperature in the skin area can indicate inflammation or infection, which frequently accompanies pressure injuries. Recognizing abnormal temperature gradients is vital; it may suggest that the body is responding to an injury or infection, warranting close monitoring and potentially aggressive intervention strategies, including topical treatments or systemic infection management.
- Pérdida parcial de espesor de la dermis: Partial-thickness loss can be suggestive of a progressing injury that reflects inadequate management of the pressure areas. Clinically, assessing the depth and characteristics of the wound can help healthcare providers evaluate healing potential and necessary interventions, such as pressure relief, wound care, and nutritional support to enhance recovery.
- Área púrpura localizada de piel intacta descolorida: This characteristic indicates potential deep tissue injury, presenting as a discolored area of intact skin. The identification of such a condition suggests that deeper tissues are affected, which may not present with overt signs. Clinically, this could require more frequent assessments and innovative preventive measures to avoid the worsening of the injury, including specialized support surfaces and regular repositioning.
- Úlcera cubierta por escara / esfacelo: A wound that is open yet covered by eschar indicates the complexity of managing pressure injuries. The presence of necrotic tissue signifies a need for skilled assessment and debridement to optimize healing. Clinically, thorough examination and appropriate management protocols are necessary, as these wounds can harbor infections and impede healing if not treated correctly.

Related Factors (Etiology) of the NANDA-I Diagnosis

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

External Contributing Factors
- Microclima alterado entre la piel y la superficie de soporte: The skin requires a stable microclimate to maintain integrity. Alterations in humidity and temperature due to inadequate bedding or environmental conditions can lead to maceration or desiccation of the skin, diminishing its protective barrier. This increases susceptibility to pressure injuries as the skin becomes more fragile and prone to breakdown under external pressures.
- Dificultad para que el cuidador levante al paciente completamente de la cama: If caregivers struggle to reposition or lift the child due to physical limitations or lack of proper equipment, certain areas will remain under increased pressure for extended periods. The continuous unrelieved pressure on these areas, especially bony prominences, can lead to ischemia and subsequent tissue death, manifesting as pressure injuries.
- Acceso inadecuado a equipo apropiado: Without the right assistive devices, such as transfer sheets or lifts, caregivers may resort to dragging or sliding the child across surfaces, contributing to friction injuries while also failing to effectively relieve pressure. The absence of appropriate tools can hinder mobility and increase injury risk remarkably.
- Conocimiento inadecuado del cuidador sobre métodos apropiados: Caregivers who lack training may not understand the importance of frequent repositioning or may use incorrect techniques that can exacerbate pressure. Education on proper patient handling and pressure injury prevention is crucial for minimizing risks and ensuring safe and effective care.
- Nivel de humedad de la piel inapropiado: The skin's vulnerability increases significantly when it is either too dry or overly moist. Dry skin can lead to cracking and fissures, while excessive moisture can cause skin maceration, both of which compromise the skin's structural integrity and elevate the likelihood of pressure injury formation.
- Uso de ropa de cama con inadecuadas propiedades de absorción de humedad: Bedding that does not properly absorb moisture can create an unsafe microenvironment. Insufficient moisture-wicking properties can lead to skin moisture pooling underneath the child, increasing exposure to shear and friction forces alongside continuous pressure, which fosters an ideal setting for pressure injuries.
Internal Contributing Factors
- Disminución de la actividad física: A lack of movement exacerbates pressure, particularly in children who are cognitively or physically unable to reposition themselves. A sustained pressure on the same areas leads to blood flow restriction, which can increase the risk of tissue necrosis and subsequent pressure injury formation.
- Piel seca: When the skin lacks adequate hydration, its elasticity and resiliency decrease, leading to increased risk for abrasions and injuries. Dry skin is more vulnerable to mechanical damage when pressure is applied, potentially resulting in pressure injuries.
- Adherencia inadecuada al régimen de tratamiento de incontinencia: Inadequate management of incontinence can lead to prolonged exposure to moisture, which damages the skin and increases the risk of developing pressure injuries. Likewise, the co-occurrence of moisture and pressure can significantly amplify tissue damage risks.
- Desnutrición proteico-energética: Inadequate protein and energy intake can impair skin and tissue development, reducing wound healing capacity and making skin more susceptible to breakdown under pressure. Malnourished children are prone to having thinner skin and less subcutaneous tissue, which are critical protective mechanisms against pressure injuries.

At-Risk Population for the NANDA-I Diagnosis

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

Children in Intensive Care Units (ICU)
This population is particularly vulnerable due to their critical health status and frequently limited mobility. Many children in ICUs are suffering from severe medical conditions that necessitate extended periods of bed rest and immobilization. Such environments may result in prolonged pressure on specific areas of the body, especially bony prominences. Additionally, the presence of various medical devices and lines, such as intravenous (IV) lines, can further increase local pressure and impede blood flow, exacerbating the risk for pressure injuries. The physiological impact of their illnesses and treatments may also compromise skin integrity and wound healing responses, making them more susceptible.
Children in Long-term Care Facilities
Children residing in long-term care settings are at a heightened risk of pressure injuries due to their extended stays in a confined position. This population often includes those with chronic conditions that limit their mobility. The enduring presence in bed or seated positions can lead to continuous pressure on skin over bony areas. Furthermore, these facilities may have varying levels of staffing and resources which can influence the quality of care and frequency of repositioning, essential interventions in preventing pressure injuries. The complex medical needs of these children can also lead to additional challenges in skin care management, increasing their vulnerability.
Children with Abnormal Body Mass Index (BMI)
Children with either obesity or undernutrition may experience increased risk for pressure injuries due to underlying physiological factors. Obese children may have increased fat deposits that create uneven pressure distribution on the skin, along with a higher likelihood of skin folds where moisture accumulation can lead to skin breakdown. Conversely, undernourished children often have less subcutaneous tissue and may experience fragile skin, making them more prone to injuries. Moreover, both ends of the BMI spectrum can affect mobility and physical activity levels, limiting the child’s ability to shift positions and relieve pressure naturally, thereby increasing the likelihood of sustained pressure injury risk.
Children with Developmental and Growth Disorders
This group includes children with conditions that may limit their motor abilities or disrupt normal growth and development patterns. These children often require specialized care and may be bedridden or have limited mobility, which significantly raises their risk for pressure injuries since they are unable to reposition themselves adequately. Conditions such as cerebral palsy, muscular dystrophy, or spina bifida can restrict movement and create abnormal pressures on certain body areas. Additionally, developmental disabilities may prevent children from effectively communicating discomfort or pain, further complicating timely interventions against pressure injuries and enhancing their risk.

Associated Conditions for the NANDA-I Diagnosis

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

Anemia
Anemia, characterized by a deficiency in red blood cells or hemoglobin, can severely compromise oxygen delivery to tissue. This condition is particularly concerning in children with pressure injuries, as the lack of adequate oxygen can impede the healing process of already compromised skin. In a child with a pressure injury, the presence of anemia can exacerbate ischemia, promoting further tissue damage and increasing susceptibility to infection. Clinically, this necessitates careful monitoring of hemoglobin levels and consideration of iron supplementation or other interventions that can enhance erythropoiesis as part of the broader care plan.
Cardiovascular Diseases
Cardiovascular diseases can lead to altered circulation, which is critical in the pathophysiology of pressure injuries. Conditions that impair blood flow can hinder the body's natural healing processes and exacerbate the risk of tissue ischemia. In children, any pathology affecting vascular health—such as congenital heart defects or acquired conditions—can pose substantial risks. This impairment can be particularly harmful in localized areas experiencing constant pressure, as inadequate blood supply can delay healing and increase the risk of secondary complications, including systemic infections. Recognizing these risks is vital for healthcare providers when assessing and planning care for a child at risk for pressure injuries.
Immobility
Immobility is one of the most significant risk factors for the development of pressure injuries, particularly in children who may have neurological conditions or post-surgical limitations. Prolonged pressure on specific body areas leads to local ischemia, resulting in tissue necrosis if not adequately addressed. The inability to shift weight or change positions inhibits circulation and exacerbates tissue breakdown. Thus, it is imperative to implement frequent repositioning schedules, employ pressure-relieving devices, and engage in therapeutic interventions aimed at enhancing mobility whenever possible. Addressing immobility is essential for both prevention and management of pressure injuries in this vulnerable population.
Physical Trauma
Any physical trauma, including abrasions, lacerations, or blunt injuries, can significantly increase a child's risk of developing pressure injuries. These injuries can disrupt the integrity of the skin barrier, making it more susceptible to undermining effects of pressure and friction. Moreover, the psychological impact of trauma may lead to treatments or immobilization strategies that further increase pressure in other areas. Additionally, children who experience trauma may have diminished mobility or altered sensation, compounding their risk profile. Understanding the implications of trauma is crucial, as it directly influences the nursing assessment, intervention strategies, and ongoing monitoring to ensure optimal recovery and skin integrity.

NOC Objectives / Expected Outcomes

For the NANDA-I diagnosis "Child 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 relevant because it directly measures the health of the child's skin, particularly in areas at risk for pressure injuries. The goal is to achieve intact skin without any signs of injury or breakdown, which is critical for preventing further complications and promoting healing.
Pain Control
Control of pain is essential in children with pressure injuries, as pain can inhibit mobility and increase stress, further complicating healing. Monitoring this outcome aims to ensure that pain is managed effectively, thereby improving the child's comfort and willingness to engage in necessary movements or interventions.
Positioning
This outcome pertains to the child's ability to maintain an optimal position to alleviate pressure on vulnerable areas. Effective positioning can prevent pressure injuries from worsening and supports the overall healing process, making it crucial in the management of pressure injuries in children.
Nutrition Status
Adequate nutrition is fundamental for wound healing and skin integrity. This outcome is relevant as it measures the child’s nutritional intake and status, which should be monitored to ensure that the child receives essential nutrients necessary for recovery from pressure injuries.

NIC Interventions / Nursing Care Plan

To address the NANDA-I diagnosis "Child 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:

Skin Surveillance
This intervention involves routinely assessing the child’s skin for signs of pressure injury formation, including redness, induration, or ulceration. Early detection is crucial in preventing further deterioration and allows for timely intervention, which can significantly reduce the likelihood of pressure injury development.
Pressure Injury Management
This intervention includes the application of appropriate dressings and topical agents based on the size and stage of the pressure injury. By using products that promote a moist healing environment and protect the wound, this intervention supports optimal healing and minimizes pain, thereby addressing the child's discomfort and promoting recovery.
Positioning
Positioning involves changing the child’s position every two hours to relieve pressure on bony prominences and improve circulation. This intervention is essential in preventing the occurrence of pressure injuries, as it helps distribute weight evenly and reduces localized pressure on vulnerable areas, ultimately enhancing skin integrity.
Nutrition Management
Providing consultation and support for nutritional needs is integral to promoting skin health and wound healing. This intervention includes ensuring adequate hydration and protein intake that supports tissue repair processes, essential for prevention and management of pressure injuries.
Patient and Family Education
Offering education about pressure injury prevention strategies and skin care to the child and their caregivers empowers them in the self-management of skin integrity. This intervention is designed to promote awareness of positioning, hygiene, and nutrition, contributing to the overall prevention of pressure injuries.

Detailed Nursing Activities

The NIC interventions for the NANDA-I diagnosis "Child 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: Skin Surveillance

Conduct a visual skin assessment at least once per shift, checking for any signs of redness, swelling, or breakdown, to ensure early detection of pressure injuries.
Document findings in the patient’s chart, noting areas of concern and changes over time, which helps in tracking the progression or improvement of skin integrity.
Use a standardized skin assessment tool, such as the Braden Scale for Predicting Pressure Sore Risk, to quantify risk levels and monitor changes objectively.

For the NIC Intervention: Pressure Injury Management

Apply appropriate wound dressings based on the stage of pressure injury, ensuring to select materials that maintain a moist wound environment, which is essential for optimal healing.
Assess and clean the pressure injury site as necessary, using sterile techniques, to minimize the risk of infection and promote effective healing.
Administer prescribed topical treatments or medications, such as antimicrobial ointments or pain relief agents, as indicated by the wound's condition.

For the NIC Intervention: Positioning

Change the child's position every two hours using pressure-relieving techniques and devices, such as cushions or specialized mattresses, to distribute weight evenly.
Educate staff and family members about proper positioning techniques to prevent pressure on bony prominences, encouraging active participation in care.
Document any position changes and their effectiveness in reducing pressure marks or discomfort, aiding in the assessment of the child's ongoing care needs.

Practical Tips and Advice

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

Regular Position Changes

Change your child's position every 2 hours to relieve pressure on vulnerable areas. This helps prevent pressure injuries by improving blood flow and reducing the risk of skin breakdown.
Use Supportive Cushions

Invest in special cushions or mattresses designed to reduce pressure. These items create a barrier between your child's skin and the surface they are on, distributing weight more evenly and minimizing the risk of injury.
Maintain Skin Hygiene

Keep your child's skin clean and dry to prevent irritation and infection. Regular bathing with gentle soap and frequent checks for any signs of redness can help catch potential issues early.
Ensure Proper Nutrition

Provide a balanced diet rich in proteins, vitamins, and minerals to support skin health and healing. Proper nutrition strengthens skin integrity and promotes faster recovery from any existing pressure injuries.
Educate and Involve Your Child

Teach your child about the importance of skin care and injury prevention. Encourage them to communicate any discomfort or changes in their skin, fostering awareness and proactive self-care.
Monitor for Symptoms

Regularly check for any signs of pressure injuries, such as redness, swelling, or pain. Early detection can facilitate timely intervention and reduce complications, making it critical for caregivers to stay vigilant.

Practical Example / Illustrative Case Study

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

Patient Presentation and Clinical Context

A 9-year-old male, with a history of cerebral palsy and limited mobility, presented to the pediatric unit with complaints of localized pain in the sacral area. The mother reported that he had been bedridden for long periods during a recent hospital stay for respiratory illness, contributing to a potential risk for pressure injuries.

Nursing Assessment

During the assessment, the following significant data were collected:

Skin Integrity: Notable erythema and localized swelling observed over the sacral area.
Patient Report: Patient expresses discomfort when pressure is applied to the affected area.
Mobility Assessment: Limited mobility noted; the patient requires assistance for repositioning.
Nutrition: The mother reports decreased appetite over the past week.
Braden Scale Score: Score of 10 indicating high risk for pressure injury.

Analysis and Formulation of the NANDA-I Nursing Diagnosis

The analysis of the assessment data leads to the identification of the following nursing diagnosis: Child pressure injury. This conclusion is based on the observable erythema and swelling in the sacral area, coupled with the patient's limited mobility and high-risk score on the Braden Scale, which indicate underlying factors contributing to the development of pressure injuries.

Proposed Care Plan (Key Objectives and Interventions)

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

Objectives (Suggested NOCs)

Maintain skin integrity and prevent further pressure injuries.
Improve nutrition status to support skin healing.

Interventions (Suggested NICs)

Pressure Injury Prevention:
- Reposition the patient every two hours to relieve pressure on the affected area.
- Use pressure-relieving devices such as specialty mattresses or cushions.
Nutritional Support:
- Consult a dietitian to develop a high-protein diet to promote healing.
- Encourage oral intake of fluids and supplements as needed.

Progress and Expected Outcomes

With the implementation of the proposed interventions, it is expected that the patient will show signs of improved skin integrity, including reduced erythema and swelling over the sacral area, as well as a decrease in pain complaints. Improvements in nutritional intake will further support the healing process. Continuous monitoring will allow evaluation of the plan's effectiveness.

Frequently Asked Questions (FAQ)

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

What is a child pressure injury?

A child pressure injury, often referred to as a pressure ulcer or bedsore, occurs when there is prolonged pressure on the skin, leading to damage. This is particularly concerning for children, as their skin is sensitive and can be easily injured.

What are the common causes of pressure injuries in children?

Common causes include prolonged immobility, such as in children with certain medical conditions, inadequate nutrition, and moisture from sweat or incontinence. These factors can impede blood flow to the skin, increasing the risk of injury.

How can pressure injuries in children be prevented?

Preventative measures include regular repositioning to relieve pressure points, maintaining good skin hygiene, ensuring proper nutrition, and using supportive surfaces like special mattresses and cushions.

What are the signs of a pressure injury in a child?

Signs of a pressure injury may include redness or discoloration of the skin, swelling, warmth, or a change in texture. In more severe cases, blisters or open wounds may develop.

How is a child pressure injury treated?

Treatment involves relieving pressure on the affected area, keeping the wound clean and covered, and ensuring proper nutrition for healing. In some cases, medical intervention may be necessary for severe injuries.