Risk for neonatal pressure injury

Domain 11. Safety-protection
Class 2. Physical injury
Diagnostic Code: 00288
Nanda label: Risk for neonatal pressure injury
Diagnostic focus: Pressure injury

Introduction to Nursing Diagnosis – Risk for Neonatal Pressure Injury

Nursing diagnosis is a part of nursing process and involves recognizing, diagnosing, and predicting responses to health problems in the neonate. The identification of nursing diagnosis helps healthcare professionals provide individualized care tailored to meet the needs of each particular patient. Healthcare professionals often utilize the NANDA International nursing diagnosis taxonomy to develop and apply nursing diagnosis for neonatal patients. The effectiveness of nursing diagnosis can assist in the successful outcome of neonatal assessment and treatment.

NANDA Nursing Diagnosis Definition

NANDA International’s definition of “Risk for Neonatal Pressure Injury” is a state in which an individual can experience tissue damage due to pressure on that area. This type of injury can occur when one area of the body is not supported or relieved from external pressure over time. The pressure placed on the tissue can cause damage to the skin or other body part beneath it. The risk factors associated with neonatal pressure injury can lead to further complications in the neonate’s overall health if left untreated.

Risk Factors

There are several risk factors associated with neonatal pressure injury. These risk factors include:

• Prematurity: Premature babies are born more vulnerable to potential complications due to the immaturity of their skin. They may also have an immature stress response system which can make them more susceptible to pressure injury.
• Malnutrition: A lack of nutrition can be a contributing factor to the development of pressure injuries as the body has less energy stores to draw from when healing or fighting infections.
• Immobility: Immobility can increase the risk of pressure injury due to the long period of time that the body part remains stationary, leading to increased pressure at that specific location.
• Fluid/Electrolyte Imbalance: Electrolyte imbalances can lead to a decrease in the blood flow to the skin, making the skin more vulnerable to injury.
• Neurological Impairment: A neurological impairment can prevent the infant from feeling pain or sensing changes in temperature due to medical conditions such as cerebral palsy.
• Medications: Certain types of medications can lead to an imbalance within the body. This can result in decreased blood flow and further increase the risk of pressure injury.
• Age/ Weight: The age and weight of the infant can influence their vulnerability to pressure injury due to their reduced movement abilities. The older and heavier the infant, the higher the risk of injury.

Associated Conditions

The associated conditions of neonatal pressure injury can include:

• Skin Erosions/Ulcerations: These are open sores that can form as a result of pressure placed on the skin.
• Infections: The infection within the wound can spread throughout the body and result in further complications for the infant.
• Deformations: Long-term distortions of the skin can result from neonatal pressure injury.
• Gangrene: If the injury is left untreated the tissue can start to die resulting in a necrotized state.
• Sepsis: Bacteria can enter the wound leading to a systemic infection in some cases.

Suggestion of Use

It is important for healthcare professionals to be aware of the areas and children most vulnerable to developing pressure injuries. Prompt recognition and proper management of neonatal pressure injuries is necessary to reduce the potential of developing long-term medical complications. Understanding the risk factors and associated conditions can help the healthcare professional provide appropriate care and improve the quality of life for those affected.

Suggested Alternative NANDA Nursing Diagnosis

Other NANDA International nursing diagnoses applicable for neonatal care include:

• Ineffective Health Maintenance: This diagnosis suggests that the individual’s ability to maintain their health has been compromised.
• Abnormal Skin Integrity: This diagnosis covers states of skin abnormality that could lead to further tissue inflammation or infection.
• Activity Intolerance: This diagnosis indicates the individual’s intolerance of physical activity and suggests a potential lack of awareness of the need to rest and conserve energy.
• Powerlessness: This diagnosis suggests the individual feels incapable of managing or coping with their illness.
• Impaired Comfort: This diagnosis refers to discomfort due to changes in tissue integrity or functioning of the body.
• Disturbed Sleep Pattern: This diagnosis suggests the difficulty in achieving quality sleep due to pain, anxiety or other disturbances.

Usage Tips

When using NANDA International nursing diagnosis for neonatal care, it is important to properly assess the condition of the patient. It is important to consider the patient’s history, symptoms, physical findings, laboratory data, and response to interventions. Using evidence-based research is also necessary to properly diagnose and determine the priority of care required.

NOC Outcomes

Nursing Outcome Classification (NOC) is a classification system widely used by many healthcare organizations for the evaluation of nursing outcomes. Utilizing this system helps define and identify the expected outcomes of nursing interventions. In the care of neonates, the following outcomes can be used:

• Skin Integrity: This outcome measures the maintenance of skin integrity from infection or injury.
• Sleep Pattern :This outcome measures the infant’s ability to attain an adequate level of rest.
• Tissue Perfusion :This outcome assesses the level of oxygen delivery to the tissues and organs of the baby.
• Body Temperature :This outcome assesses the ability of the newborn’s body to maintain a balanced temperature.
• Caregiver Emotional Support :This outcome evaluates the level of emotional support the caregiver provides to the infant.
• Pain Management :This outcome assesses the infant’s ability to cope with their discomfort despite the potential of developing pressure sores.

Evaluation Objectives and Criteria

After determining the appropriate NANDA International nursing diagnosis and setting up the desired NOC outcomes, healthcare professionals must also identify specific criteria for evaluating the success of the nursing intervention. Evaluation objectives should be measurable and achievable and based upon the desired outcome. Examples of evaluation criteria include: reduction of erythema and skin breakdown, improvement in nutritional intake, adequate rest and sleep patterns, and avoidance of long-term deformations.

NIC Interventions

Nursing Interventions Classification (NIC) is also a widely accepted system of interventions used by healthcare organizations. The most applicable NIC interventions for neonatal care include:

• Pressure Relief/Redistribution: This intervention relieves the pressure from susceptible areas by providing various supports and repositioning devices to redistribute the pressure.
• Skin/Wound Care: This intervention promotes healing of the wound, reduces scarring, improves hygiene, and prevents further damage.
• Nutrition management: This intervention monitors and provides the necessary nutrients to aid in the regeneration of the affected area.
• Hydration Therapy: This intervention increases the fluid intake to maintain optimal hydration, which can improve wound healing.
• Positioning: This intervention relieves areas of the body prone to critical pressure points while maintaining circulation.
• Pain Management: This intervention is used to reduce discomfort and promote relaxation in the patient. This can be accomplished through a combination of techniques such as distraction and music therapy.
• Education: This intervention provides caregivers with the necessary knowledge and skills to effectively care for the infant.

Nursing Activities

For neonatal pressure injury, the nurse’s activities should focus on prevention, control, and treatment. The nurse should closely evaluate the patient for any signs of injury, reassess areas of frequent pressure, mobilise the patient to maintain circulation, and ensure proper repositioning and support. The nurse should also regularly monitor the patient’s skin integrity and implement appropriate interventions if skin breakdown is identified. Other activities include screening families in order to identify risk factors, teaching family members how to maintain skin integrity, and educating them on the importance of preventing pressure injury.

Conclusion

Neonatal pressure injury is a serious concern in the neonatal ICU and proactive steps are necessary to prevent and manage the risk of damage. Through an understanding of the risk factors and associated conditions, healthcare professionals can identify neonatal pressure injury and create a plan of care in order to reduce the potential of developing long-term medical complications. Utilizing nursing diagnosis, NOC outcomes, and NIC interventions, healthcare professionals can provide appropriate care and improve the quality of life for those affected.

5 FAQs

1. What is Nursing Diagnosis?
   Nursing diagnosis is a part of nursing process and involves recognizing, diagnosing, and predicting responses to health problems in the neonate. The identification of nursing diagnosis helps healthcare professionals provide individualized care tailored to meet the needs of each patient.
2. What Does the NANDA International Definition of “Risk for Neonatal Pressure Injury” Mean?
   NANDA International’s definition of “Risk for Neonatal Pressure Injury” is a state in which an individual can experience tissue damage due to pressure on that area. This type of injury can occur when one area of the body is not supported or relieved from external pressure over time
3. What Are the Risk Factors for Neonatal Pressure Injury?
   The risk factors associated with neonatal pressure injury can include prematurity, malnutrition, immobility, electrolyte imbalance, neurological impairment, medications, age, and weight.
4. What Are the Associated Conditions of Neonatal Pressure Injury?
   The associated conditions of neonatal pressure injury can include skin erosions/ulcerations, infections, deformations, gangrene, and sepsis.
5. What Are the Different Usages Tips of NANDA International Nursing Diagnosis for Neonatal Care?
   When using NANDA International nursing diagnosis for neonatal care, it is important to properly assess the condition of the patient. It is important to consider the patient’s history, symptoms, physical findings, laboratory data, and response to interventions. Using evidence-based research is also necessary to properly diagnose and determine the priority of care required.

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