Pressure Injury In The Child

Introduction to Nursing Diagnosis - Pressure Injury In The Child

Pressure injury in children is caused when the capillaries in a child’s skin succumb to extreme pressure or shear force. This leads to breaks in the capillaries, which then develops into a bruise, blister or wound. This can cause extreme discomfort and may also have long-term complications if left untreated.

Nursing Diagnosis Definition

The nursing diagnosis of Pressure Injury in The Child relates to the preservation and promotion of health, as well as the alleviation of suffering related to cases of extreme pressure – or shear force – on the child’s skin.

Defining Characteristics

Subjective

• Child complains of discomfort
• Child expresses fear of developing a pressure injury

Objective

• Visual or tactile evidence of irritation
• Swelling or discoloration of the affected area

Related Factors

There are various related factors that might increase the chances of a pressure injury:

• Consistent bedridden conditions
• Relying on a wheelchair for movements
• Lack of change in position and repositioning
• Friction caused by moving a child with mechanical methods
• Poor circulation
• Moisture or excessive perspiration
• Nutritional deficiencies

Risk Population

Certain populations are at a higher risk of developing a pressure injury than others, including those with pre-existing blood vessel or skin conditions and those who are considered to be vulnerable to pressure injuries, such as:

• Neonates and premature babies
• Children with limited mobility
• Children with advanced neurological diseases
• Children with genetic disorders
• Immunocompromised children
• Children with metabolic disorders

Associated Problems

Pressure injuries can lead to many other medical problems, such as infection, tissue death, significant blood loss, nerve damage and even long-term disability. It is important to seek medical attention immediately when signs of a pressure injury are identified.

Suggestions for Use

When treating or attempting to prevent a pressure injury, it is important to remember to assess the site often and to implement preventive measures, such as:

• Repositioning the child with proper padding
• Providing necessary nutrition for healthy skin
• Treating underlying disorders which make the child prone to injury
• Keeping the skin clean and dry
• Using the correct equipment to protect the child
• Adding additional layers of padding over bony areas
• Exercising caution while using mechanical lifts
• Reducing friction and shearing forces

Suggested Alternative Nursing Diagnosis

Alternative NANDA diagnoses to consider when assessing a child with potential pressure injuries are:

• Impaired Skin Integrity
• Ineffective Tissue Perfusion
• Risk for Infection
• Risk for Fluid Volume Deficit
• High Risk for Altered Tissue Perfusion

Usage Tips

When diagnosing a pressure injury in children, it is important to bear in mind the following points:

• Ensure that the current interventions are adequate and documented
• Consult a physician or surgeon to rule out any other complications
• Assess any potential risk factors and document them
• Observe behavior and note any changes
• Be alert for any potential signs of infection
• Evaluate treatments regularly to note progress

NOC Results

NOC outcomes(Nursing Outcomes Classification) to consider when managing a child at risk of pressure injuries include:

• Skin Integrity: Assesses the ability of the patient to maintain the normal integrity and defensive properties of the skin and mucous membranes
• Pain Level: Assesses the patient’s level of discomfort
• Risk Control: Assesses the patient’s ability to shed risk factors during treatment
• Knowledge: Assesses the patient's understanding of the disease, treatment and management
• Mobility: Assesses the mobility of the patient

NIC Interventions

NIC interventions (Nursing Interventions Classification) to consider when trying to prevent or treat a pressure injury include:

• Injury Prevention: Interventions designed to minimize the chance of developing a pressure injury
• Pressure Management: Interventions designed to reduce the pressure being applied to the affected area
• Fluid Balance Monitoring: Interventions designed to observe for normal hydration and electrolyte status
• Repositioning: Interventions designed to reduce the amount of consistent pressure being maintained on the skin
• Skin Care: Interventions designed to provide proper nutrition and hydration, along with maintaining cleanliness of the skin

Conclusion

Pressure injury in a child is a serious health concern, and it is important to identify any potential risk factors as early as possible. It is also essential for nursing staff to be extra careful when caring for children at risk of developing a pressure injury and ensure that preventive measures and treatments are furthered.

FAQ

• What is a nursing diagnosis? A nursing diagnosis is a standardized language developed by NANDA International that categorizes and describes client concerns and response to health care challenges.
• What are NOC and NIC interventions? NOC and NIC interventions (Nursing Outcome Classification and Nursing Interventions Classification) represent indicators that measure the patient’s progress and the interventions used to achieve results.