Risk for adult pressure injury

Risk for adult pressure injury

Domain 11. Safety-protection
Class 2. Physical injury
Diagnostic Code: 00304
Nanda label: Risk for adult pressure injury
Diagnostic focus: Pressure injury

Nursing diagnosis ‘Risk for adult pressure injury’ is an important nursing intervention‌ meant to prevent future injuries. Pressure injuries are a major source of preventable harm and can lead to serious medical complications if left untreated or undiagnosed. Being familiar with the NANDA nursing diagnosis definition, along with a good list of risk factors and associated conditions, is key to providing the best care.

Introduction to NANDA Nursing Diagnosis

NANDA Nursing Diagnosis Definition

The Nursing Intervention Classification (NIC) and Nursing Outcomes Classification (NOC) system created by NANDA International defines nursing diagnoses as “clinical judgements” and gives specific examples, such as risk for adult pressure injury. This nursing diagnosis is made when there is a potential that an adult patient will develop a pressure injury due to extended periods of immobility.

Risk Factors

Risk factors for adult pressure injuries include:

  • Extended durations of immobilization due to age, mobility, activity limitations, or post-operative recovery.
  • Inadequate hydration, diet, and nutrition.
  • Reduced circulation caused by some medical conditions.
  • Medications or medical treatments reducing skin elasticity or exacerbating existing skin conditions.
  • Long-term use of medical procedures such as indwelling catheters or pipes.

Associated Conditions

Pressure injuries tend to occur simultaneously with other medical conditions, such as:

  • Chronic diseases, such as diabetes.
  • Hip fractures.
  • Urinary infections.
  • Gastrointestinal bleeding.
  • Venous insufficiency, which arises from poor circulation.

Suggestions for Use

Nurses can help provide the best care possible by following a few simple guidelines. The most important action to take is frequent repositioning of patients who are prone to immobility. Reassessing patients every 2 hours to check for risk factors is critical. Nurses should also look for signs of new or deteriorating existing pressure injuries. If a pressure injury is identified, nurses should start by assessing the stage and then use best practices to treat them.

Suggested Alternative NANDA Nursing Diagnosis

Other nursing diagnosis related to pressure injuries include:

  • Ineffective Tissue Perfusion.
  • Risk for Fluid Volume Deficit.
  • Acute Pain.
  • Impaired Physical Mobility.
  • Impaired Skin Integrity.

Usage Tips

When making a nursing diagnosis, nurses should assess the patient’s risk factors and associated conditions before giving a definitive diagnosis. A comprehensive physical assessment should also be conducted on regular intervals to identify any emerging or worsening pressure injuries. Bed rest times should be kept to a minimum to reduce the risk of pressure injuries occurring.

NOC Outcomes

The Nursing Outcomes Classification (NOC) system provides a list of expected outcomes to assess in evaluating patient progress after receiving nursing interventions. These outcomes include:

  • Skin Integrity: Increase in intact skin.
  • Tissue Perfusion: Increase in tissue perfusion.
  • Nutrition: Increase in nutritional intake.
  • Mobility: Increase in mobility.
  • Hygiene: Increase in hygiene.

Evaluation Objectives and Criteria

Objectives are typically developed to measure the success of a treatment plan. Evaluation criteria include such factors as:

  • Marked improvement in patient skin integrity.
  • Sustained tissue perfusion.
  • Maintenance of nutrient balance and enhanced nutritional intake.
  • Regular ambulating with or without assistance.
  • Consistent hygiene and grooming.

NIC Interventions

The Nursing Intervention Classification (NIC) system identifies the recommended practices to carry out in clinical settings. These practices relate to the prevention, detection, and management of pressure injuries, such as:

  • Protecting skin – positioning, padding of bony prominences, use of skin moisturizer, special booties, beds.
  • Promoting skin/scalp hygiene and skin/scalp care.
  • Monitoring hydration/nutrition levels, especially when immobile.
  • Providing adequate comfort measures.
  • Monitoring for wound progression and subsequent stages.

Nursing Activities

Once a diagnosis is confirmed, nurses should focus their attention on providing prompt and attentive care to reduce the chances of the pressure injury getting worse. This includes taking preventative measures such as:

  • Turning and positioning the patient regularly.
  • Providing support surfaces and supportive skin care products.
  • Maintaining proper hydration, nutrition, and blood flow to the affected area.
  • Conducting frequent skin assessments.
  • Educating the patient on the importance of risk factor reduction and lifestyle changes.

Conclusion

Nursing diagnosis ‘Risk for Adult Pressure Injury’ is an important concept that needs specialized attention. Besides having knowledge of risk factors and associated conditions, it is essential to understand how to evaluate and manage pressure injuries. This article has discussed the NANDA nursing diagnosis relating to this topic and also listed some necessary steps to be taken for effective treatment.

5 FAQs

1. What is a NANDA nursing diagnosis?
A NANDA nursing diagnosis is a clinical judgement about a patient’s risk for illness or injury based on the collection of evidence and analysis of data.

2. What is a risk for adult pressure injury?
Risk for adult pressure injury is a nursing diagnosis used to describe the potential for pressure injuries due to prolonged immobilization in adult patients.

3. What are some risk factors for adult pressure injuries?
Risk factors for adult pressure injuries include immobility, dehydration and poor nutrition, reduced circulation due to medical conditions, medications reducing skin elasticity, and long-term use of medical procedures.

4. What conditions are associated with pressure injuries?
Pressure injuries can be associated with chronic diseases, hip fractures, urinary infections, gastrointestinal bleeding, and venous insufficiency.

5. What activities should nurses carry out when it comes to pressure injuries?
When it comes to preventing, detecting and managing pressure injuries, nurses should practice frequent repositioning, reassess for risk factors every two hours, look for signs of new or deteriorating existing injuries, assess the stage of a existing pressure injury and use best practices to treat them.

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