Domain 11. Safety-protection
Class 2. Physical injury
Diagnostic Code: 00287
Nanda label: Neonatal pressure injury
Diagnostic focus: Pressure injury
Introduction to Nursing Diagnosis Neonatal Pressure Injury
Neonatal pressure injury is a type of wound that affects babies during their first 28 days of life. These injuries occur due to improper positioning or prolonged friction between the baby’s skin and the surface it is placed on. Pressure injuries can cause significant physical, emotional and financial harm to a newborn and their family. As such, nursing diagnosis neonatal pressure injury is an important aspect of caring for these little ones. This diagnosis involves a comprehensive approach to identifying, preventing and treating pressure injuries in newborns.
NANDA Nursing Diagnosis Definition
NANDA nursing diagnosis neonatal pressure injury is a condition characterized by localized areas of tissue damage resulting from contact between the baby’s skin and a surface. It is typically classified into four grades: stage 1, 2, 3 and 4, with 4 being the most severe. This diagnosis includes assessment of risk factors such as low birth weight, prematurity, underlying medical conditions, skin integrity, activity and environment.
Defining Characteristics
- Subjectives: reduced mobility, crying, discomfort, irritability.
- Objectives: changes in the color or texture of the skin in the affected area, changes in temperature, decreased localized sensation, presence of any lesions.
- Physical Factors: birth weight, prematurity, chronic illness.
- Environmental Factors: inadequate nutrition, poor hygiene, rough surfaces.
- Therapeutic Factors: non-adherence to skin care recommendations, prolonged immobilization, healthcare staff not following protocols or policies.
Explanation: These factors can contribute to the development of pressure injuries due to increased skin fragility or prolonged contact with a surface. Additionally, certain environmental and therapeutic factors can increase the risk of injuries caused by pressure.
At Risk Population
- Premature and full-term infants.
- Infants with birthweights below 2500 grams.
- Infants with underlying medical conditions.
- Infants with compromised skin integrity.
Explanation: These populations are at an increased risk of neonatal pressure injuries due to their fragile skin, decreased mobility, and/or underlying medical conditions. Proper assessment and monitoring of these infants is essential in order to prevent and/or manage pressure injuries.
Associated Conditions
- Skin breakdown.
- Infection.
- Diminished muscle function or body movement.
- Organ system failure.
Explanation: Associated conditions can be a direct result of skin breakdown or complications from damage caused by pressure. An infant with an underlying medical condition can also be at an increased risk for organ system failure if a wound caused by pressure is not managed properly.
Suggestions of Use
It is important for all healthcare professionals to be aware of and knowledgeable about neonatal pressure injury. To ensure proper assessment and management of pressure injuries, they should understand the risk factors, associated conditions, and interventions that can be implemented. Additionally, a nursing care plan should be developed and specific documentation of assessment, interventions and outcomes should be completed.
Suggested Alternative NANDA Nursing Diagnosis
- Risk for Skin Breakdown.
- Impaired Skin Integrity.
- Fragile Skin Syndrome.
- Risk for Developmental Delays.
- Ineffective Thermoregulation.
Explaination: These alternative NANDA nursing diagnoses provide additional insight into how pressure injuries affect infants and can be implemented alongside the total nursing diagnosis of neonatal pressure injuries. Skin breakdown, impaired skin integrity, and fragile skin syndrome are common results of pressure injuries, while risk for developmental delays corresponds to the decreased body movement often seen in infants with pressure injuries. Ineffective thermoregulation is a complication that can arise when an infant’s skin is damaged.
Usage Tips
- Properly position infants, especially those with underlying conditions, to minimize the risk of pressure injuries.
- When assessing an infant for a possible pressure injury, complete a comprehensive examination and document any changes in the skin’s color, texture, temperature, or sensation.
- Identify factors that increase the risk of pressure injury and take appropriate action.
- Implement skin protection methods and apply them consistently to provide optimal protection.
NOC Outcomes
- Skin Integrity: The degree to which the skin is free from lesions, intact, and capable of providing a barrier to infection and external agents.
- Immobility Level: The degree to which an individual can move independently.
- Infection Status: The degree to which the body has been invaded by pathogenic organisms.
- Tissue Perfusion: The adequacy of the blood flow to tissues.
Explanation: These outcomes indicate the progress of treatment and provide guidance to nurses on their interventions. For instance, skin integrity refers to the state of the skin and its ability to protect the body from harm, while immobility feet indicates the extent to which the patient can move independently. Infection status addresses the risk of infection as a result of wound breakdown, while tissue perfusion quantifies the measure of blood flow to the area.
Evaluation Objectives and Criteria
The evaluation should focus on the effectiveness of the interventions implemented in order to reduce the risk of pressure injuries and improve the infant’s condition. Objective criteria should include assessment of the infant’s skin integrity, immobility level, infection status, and tissue perfusion. Documentation should track changes in these measures over time to determine whether interventions have been successful in reducing risk factors, providing effective treatments, and promoting healing.
NIC Interventions
- Skin Care: Establishing and maintaining the skin integrity of the infant by providing skin assessments to identify potential pressure injury sites and providing appropriate interventions to reduce risk.
- Positioning and Support Surface Management: Providing proper support to the infant to reduce the risk of skin breakdown.
- Activity: Promoting mobility and activity to enhance healing and reduce the risk of skin breakdown.
- Infection Control: Implementing strategies to reduce the risk of infection.
- Nutrition and Hydration: Providing proper nutrition and hydration to prevent skin depletion.
Explanation: These interventions are essential in order to reduce the risk of pressure injuries and promote healing. Skin care involves assessing and maintaining the infant’s skin integrity, while positioning and support surface management provides support to decrease the risk of skin breakdown. Activity promotes optimal tissue healing and helps to diminish the risk of skin breakdown, while infection control prevents infections due to wound breakdown. Lastly, nutrition and hydration prevent skin depletion and optimize the infant’s health.
Nursing Activities
- Monitor the infant’s skin integrity, including changes in color, texture, temperature, and sensation.
- Encourage movement and activity, as tolerated.
- Provide support and repositioning, as needed.
- Administer medications as ordered.
- Promote Nutrition and Hydration.
- Assess changes in the infant’s condition and document all findings.
Conclusion
Neonatal pressure injury is a serious condition that requires a comprehensive approach in order to identify, prevent, and manage the condition. Nursing diagnosis neonatal pressure injury assists healthcare professionals in assessing risk factors, determining associated conditions, and implementing appropriate interventions to reduce the risk of pressure injuries in newborns. Nurses should be aware of this diagnosis and monitor the infant’s condition, while following established protocols and providing consistent and appropriate care.
5 FAQs
Q: What is Neonatal Pressure Injury?
A: Neonatal pressure injury is a type of wound that affects newborns during the first 28 days of life. It occurs due to prolonged friction between the baby’s skin and the surface it is placed on.
Q: Who is at Risk of Neonatal Pressure Injury?
A: Premature and full-term infants, infants with birth weights below 2500 grams, and those with underlying medical conditions are at an increased risk of developing pressure injuries.
Q: What are Some Associated Conditions?
A: Skin breakdown, infection, diminished body movement, and organ system failure can be associated with pressure injuries.
Q: What are Some NOC Outcomes?
A: Skin integrity, immobility level, infection status, and tissue perfusion are four NOC outcomes that provide guidance to nurses on their interventions.
Q: What Nursing Activities Should Be Implemented?
A: Nurses should monitor the infant’s skin integrity, encourage activity as tolerated, provide support, administer medications as ordered, promote nutrition and hydration, and assess changes in the infant’s condition.
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