Domain 11. Safety-protection
Class 2. Physical injury
Diagnostic Code: 00286
Nanda label: Risk for child pressure injury
Diagnostic focus: Pressure injury
Introduction to Nursing Diagnosis: Risk for Child Pressure Injury
Nursing diagnosis is a medical term used to describe signs and symptoms of a patient’s condition. Nursing diagnoses provide an evidence-based method for clinical practice. This type of diagnosis is used to assess, diagnose, plan and provide interventions for care and patient management. One such nursing diagnosis is “Risk for Child Pressure Injury”. This type of injury is especially hazardous in children due to their immature risk and protective factors. The purpose of this article is to help readers understand the definition, risk factors and criteria for “Risk for Child Pressure Injury” as a nursing diagnosis.
NANDA Nursing Diagnosis Definition
NANDA International describes “Risk for Child Pressure Injury” as “at risk for tissue injury due to immobility, decreased perfusion, capillary fragility, and other neurological and physiological challenges.” An at-risk diagnosis means that a patient could develop an injury due to the identified factors, unless a preventative effort is made.
Risk Factors
There are multiple risk factors associated with Risk for Child Pressure Injury. These include age, positioning, immobility, malnutrition, fragility of skin or tissue, general health status, drug therapy, and impaired sensory perception. Children who are age-related cognitive, psychomotor, or learning disabilities are also at greater risk, as are those with hypotonia or flaccid paralysis. Excess or inadequate nutrition may also put a child at higher risk for pressure injury.
At Risk Population
Certain populations are at higher risk for child pressure injuries, including neonates, infants, toddlers, preschool-age children, school-age children and those in pediatric hospitals. There is a particular risk for those placed in restraints, wheelchairs, or beds, either mechanically or manually, as well as those unable to reposition themselves due to physical or mental impairment.
Associated Conditions
Some conditions can lead to a greater incidence of pressure injury in children. Certain skin diseases – such as eczema, psoriasis, or topical steroid use – can make the skin prone to break down. Any vascular disease increases the risk of pressure injuries, as do prolonged labor, prolonged usage of mechanical equipment for medical aid, too much water intake, and any medications that might increase a child’s risk for developing a pressure injury.
Suggestions of Use
The NANDA International Nursing Diagnoses list “Risk for Child Pressure Injury” as the 11th risk diagnosis. It is important to recognize the signs and symptoms of this diagnosis quickly in order to properly protect a child from its potential adverse effects. Nurses can assess the condition of the skin periodically, which includes assessing whether there is any discoloration, maceration, warmth, or edema. Other methods of assessment for pressure injuries include pulse oximetry, skin thermometry, and capillary refill time.
Suggested Alternative NANDA Nursing Diagnoses
There are some alternative diagnoses that may be suitable for a patient exhibiting signs of pressure injury. These alternatives include Dysfunctional Grieving, Self-Care Deficit, Ineffective Health Maintenance, Risk for Impaired Skin Integrity, and Risk for Infection. Dysfunctional Grieving, for example, is a diagnosis that determines whether family members are able to meet the grieving needs of a child as they suffer from a pressure injury. Self-care Deficit is another diagnosis that helps to determine if a child has the capacity to care for him or herself against pressure injuries. Ineffective Health Maintenance checks to see if there are any environmental factors that may be putting a child at risk for pressure injuries. Risk for Impaired Skin Integrity looks at any changes in skin integrity which may have been caused by pressure injuries. Finally, Risk for Infection examines any changes in skin integrity that may cause an infection.
Usage Tips
When using this diagnosis, it is important to take into account the individual characteristics and developmental level of a child before deciding if a diagnosis of “Risk for Child Pressure Injury” is appropriate. It is also important to remember that early recognition of any signs or symptoms is key to providing protection and reducing the development of a pressure injury.
NOC Outcomes
The Nurse Outcome Classification (NOC) system is composed of 20 categories, with nine outcomes per category, that measure the effect of nurse-sensitive care of a patient. For patients at risk for child pressure injuries, the following NOC outcomes may best represent the severity and progression of the patient’s condition:
- Intact Skin: This outcome measures the presence (or absence) of skin integrity on a scale of 0 to 4, with 4 being optimal functioning. With this outcome, interventions that evaluate a patient’s skin condition and customize a plan of care to protect a patient’s skin may be necessary.
- Immobility Level: This outcome measures the amount of physical activity a patient is involved in, on a scale from 0 (totally immobilized) to 5 (fully active and unrestricted). Through this outcome, interventions that promote mobility and physical activity for a patient may be needed.
- Skin Heat Loss: This outcome measures how well heat is retained in the skin on a scale from 4 (optimal insulating properties) to 0 (low or absent heat retention). With this outcome, interventions to help promote and improve skin insulation may be necessary.
- Nutrition Status: This outcome examines the nourishment of a patient on a scale of 0 to 10, with 10 representing high nutritional status. Through this outcome, interventions to aid in achieving a balanced daily nutrition may be necessary.
- Skin Turgor: This outcome measures the moisture and elasticity of a patient’s skin on a scale from 0 (skin dry, nonelastic) to 4 (optimal skin turgor). With this outcome, interventions to improve skin turgor may be necessary.
- Skin Moisture: This outcome measures the presence of moisture in a patient’s skin on a scale from 0 (minimum hydration/no sweat present) to 4 (optimal moisture present). With this outcome, interventions to promote hydration may be necessary.
- Skin Color: This outcome measures the appearance of a patient’s skin on a scale from 0 (deeply discolored skin) to 3 (normal hue and color). With this outcome, interventions that target improving skin color may be necessary.
- Circulation Status: This outcome measures the efficiency of a patient’s circulatory system on a scale from 0 (poor/sluggish circulation) to 4 (optimal circulation). With this outcome, interventions to improve circulation may be necessary.
- Capillary Refill: This outcome measures the amount of time it takes for blood to travel from the capillaries to the heart on a scale from 0 (markedly slowed capillary return) to 4 (optimal capillary refill). With this outcome, interventions to restore normal capillary refill levels may be necessary.
Evaluation Objectives and Criteria
When assessing a patient at risk for child pressure injury, nurses must be able to identify the signs, symptoms and risk factors. An assessment should include an initial physical exam, attention to certain anatomical areas, a review of any current medications, inspection of skin color, an evaluation of nutritional status, a response test of skin elasticity, and testing of skin heat flow. Once all these criteria have been established, a treatment plan should be developed to ensure the best possible outcome.
NIC Interventions
The Nursing Intervention Classification (NIC) system is composed of 23 categories, with 87 outcomes and interventions, to measure the effectiveness of nursing interventions for a specific patient. The following NIC interventions may be beneficial in treating a child at risk for pressure injuries.
- Pressure Reduction: This intervention helps to reduce the exposure of a patient’s skin to excessive pressure. Interventions like frequent turning and repositioning, special mattresses, or cushions may be beneficial.
- Heat Therapy: This intervention involves the use of heated packs and blankets and baths to improve circulation, encourage healing, and reduce pain associated with a pressure injury.
- Fluids/Nutrition: This intervention provides adequate fluids and nutrition to the patient to help prevent dehydration and promote healing.
- Skin Integrity Enhancement: This intervention involves the use of proper cleaning, moisturizing, and bandaging techniques to protect a patient’s skin and promote healing.
- Perineal Care/Irrigation: This intervention is designed to reduce irritation and inflammation in the tissues of the perineum due to excessive moisture or stress.
- Stimulate Activity: This intervention helps to stimulate normal levels of movement and physical activity for the patient to improve circulation and reduce pressure.
- Injury Prevention Strategies: This intervention helps to develop and implement strategies to safeguard patients who are at a greater risk for pressure injuries.
- Initiate Skin Surveillance: This intervention involves monitoring a patient’s skin for any changes that may be present and developing a plan to treat any changes before it becomes a pressure injury.
Nursing Activities
In addition to the NIC interventions listed, there are several activities that nurses can do to help reduce the risk of child pressure injuries and promote healing. These activities include assessing a patient’s nutritional status, keeping accurate records to monitor progress, providing regular instruction on proper positioning and skin care, providing individualized movement plans and exercise routines, and promoting family involvement in the patient’s care.
Conclusion
“Risk for Child Pressure Injury” is a common nursing diagnosis. By understanding the definition, risk factors and criteria of this diagnosis, as well as understanding the Nurse Outcome Classification and Nursing Intervention Classification related to it, nurses will be better prepared to conduct assessments, recognize warning signs and provide necessary interventions to protect children from this type of injury.
FAQs
1. What is “Risk for Child Pressure Injury”?
Risk for Child Pressure Injury is a nursing diagnosis that indicates a child is at risk for tissue injury due to immobility, decreased perfusion, capillary fragility or other neurological and physiological issues.
2. What are the risk factors for “Risk for Child Pressure Injury”?
The risk factors for Risk for Child Pressure Injury include age, positioning, immobilization, malnutrition, fragility of skin or tissue, general health status, drug therapy and impaired sensory perception.
3. Who is at risk for Child Pressure Injury?
Neonates, infants, toddlers, preschool-age children, school-age children and those in pediatric hospitals may be at a greater risk for this type of injury, particularly if they are placed in restraints, wheelchairs, or beds, either mechanically or manually, or are unable to reposition themselves due to physical or mental impairment.
4. What are some nursing interventions for “Risk for Child Pressure Injury”?
Nursing interventions for Risk for Child Pressure Injury include pressure reduction, heat therapy, fluids/nutrition, skin integrity enhancement, perineal care/irrigation, stimulate activity and injury prevention strategies.
5. What activities can nurses perform to reduce the risk of pressure injuries to children?
Nurses can conduct regular assessments of a patient’s nutritional status, keep accurate records to monitor progress, provide regular instruction on proper positioning and skin care, provide individualized movement plans and exercise routines, and promote family involvement in a patient’s care.
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