Risk Of Adult Pressure Injury

Risk Of Adult Pressure Injury

Contents

Introduction

The nursing diagnosis of Risk of Adult Pressure Injury is defined as an individual who is at risk for soft tissue damage due to unrelieved, excessive amounts of pressure. This diagnosis is included in the 2015-2017 NANDA International Nursing Diagnoses: Definitions & Classification.

Nursing Diagnosis Definition

Risk of Adult Pressure Injury: Vulnerable to impaired skin integrity to unrelieved pressure over prolonged time frame resulting from physical or physiological pressures exceeding hypo-perfusion of tissues.

Defining Characteristics

  • Subjective
    • Verbalizes concern about risk for pressure injury
    • Reports decreased blood flow
    • Verbalizes poor skin condition
  • Objective
    • Skin discoloration
    • Decreased sensation
    • Purpura or petechiae

Related Factors

  • Decreased peripheral circulation
  • Inadequate nutrition
  • Lack of sensory perception
  • Prominence of bony structure
  • Immobility
  • Medical equipment or device application
  • Inability to reposition independently
  • Moisture-associated skin damage
  • Abrasion

Risk Populations

People at greatest risk of adult pressure injury include older adults and people with impaired mobility or consciousness, including those with a history of hypotension, poor nutrition and edema.

Associated Problems

Pressure injuries can lead to skin and tissue breakdown, infection, respiratory complications, pain, and ultimately death.

Suggestions for Use

Nurses should assess each person's risk of developing pressure injury and take steps to prevent them wherever possible. This includes research into safe positioning, good nutrition, and patient education on how to manage their own skin health.

Suggested Alternative Nursing Diagnosis

  • Impaired Skin Integrity
  • Impaired Physical Mobility
  • Risk for Infection
  • Risk for Nutrition Imbalance
  • Risk for Ineffective Airway Clearance

Usage Tips

  • Assess the patient's risk factors for developing pressure injuries.
  • Coach the patient on ways to prevent and reduce the chances of pressure injuries.
  • Assist the patient with any medical equipment that may be needed to reduce risk.
  • Provide patient education on skin health and how to care for it.

NOC Results

  • Skin Integrity: The patient's skin remains unharmed and shows no signs of pressure injuries.
  • Risk Control: The patient has taken action to reduce or eliminate risks of developing pressure injuries.
  • Mobility Level: The patient is able to move around safely, with or without assistance, to reduce pressure on the skin.
  • Self-Care: The patient is able to practice good skin care to reduce the risk of pressure injuries.

NIC Interventions

  • Skin Surveillance: Assessing the patient's skin for signs of pressure injuries and providing appropriate interventions if necessary.
  • Repositioning: Helping the patient to engage in frequent positional changes to decrease pressure on the skin.
  • Nutrition Management: Educating the patient on proper nutrition to maintain their skin's health.
  • Skin Care: Providing guidance on proper skin care and hygienic practices to reduce the risk of infection and pressure injuries.
  • Positioning Devices: Assisting the patient with devices to relieve pressure on the skin, such as lifts, cushions, mattresses, and foam wedges.

Conclusion

Risk of Adult Pressure Injury is an important nursing diagnosis to be aware of, especially when working with certain patient populations. With proper assessment, interventions, and patient education, nurses can help reduce the risk of pressure injuries, and improve the quality of life for their patients.

FAQ

  • What is the definition of Nursing Diagnosis Risk of Adult Pressure Injury?
    The nursing diagnosis of Risk of Adult Pressure Injury is defined as an individual who is at risk for soft tissue damage due to unrelieved, excessive amounts of pressure.
  • Which are the Defining Characteristics of Risk of Adult Pressure Injury?
    The defining characteristics of Risk of Adult Pressure Injury can be subjective (verbalizes concern about risk for pressure injury; reports decreased blood flow; verbalizes poor skin condition) or objective (skin discoloration; decreased sensation; purpura or petechiae).
  • What are the common Related Factors of Risk of Adult Pressure Injury?
    Common Related Factors of Risk of Adult Pressure Injury include decreased peripheral circulation; inadequate nutrition; lack of sensory perception; prominence of bony structure; immobility; medical equipment or device application; inability to reposition independently; moisture-associated skin damage; and abrasion.

Isabella White

Hello to all nursing enthusiasts! I'm Isabella White and I'm thrilled to welcome you to this space dedicated to the exciting world of nursing. Let me share a little about myself and what we can expect together on this journey. About Me: Nursing is more than just a profession to me, it's a calling. When I'm not caring for my patients or learning more about health and wellness, you'll find me enjoying the great outdoors, exploring new trails in nature, or savoring a good cup of coffee with close friends. I believe in the balance between caring for others and self-care, and I'm here to share that philosophy with you. My Commitment to You: In this space, I commit to being your reliable guide in the world of nursing. Together, we'll explore health topics, share practical tips, and support each other on our journeys to wellness. But we'll also celebrate life beyond the hospital walls, finding moments of joy in the everyday and seeking adventures that inspire us to live fully. In summary, this is a place where nursing meets life, where we'll find support, inspiration, and hopefully a little fun along the way. Thank you for joining me on this exciting journey. Welcome to a world of care, knowledge, and connection! Sincerely, Isabella White

Leave a Reply

Your email address will not be published. Required fields are marked *

Go up

Usamos cookies Más información