Risk Of Neonatal Pressure Injury

Nursing Diagnosis: Risk Of Neonatal Pressure Injury

Introduction: The presence of a pressure injury in the newborn child can be caused by numerous factors, leaving the infant vulnerable to tissue damage, infection, and long-term health implications. The nursing diagnosis for ‘Risk of Neonatal Pressure Injury’ contains all necessary information to understand, assess and intervene in order to prevent any inflammation or damage due to external or internal sources of pressure.

Nursing Diagnosis Definition

This diagnosis refers to a potential increase in risk of damage to the skin and underlying tissue because of pressure, shear, and/or friction that is a result of prolonged contact with surfaces.

Defining Characteristics

Subjective:

• Infant displays signs of discomfort while lying in one position
• Parent reports infant experiences frequent discomfort

Objectives:

• Skin appears to be stretched tightly across bony prominences when repositioned
• Tissue shows signs of discoloration and physical trauma
• A decrease in range of motion

Related Factors

Pressure injuries are cumulatively caused by multiple factors, including (but not limited to): physical immaturity, obesity, increased temperatures, sliding, improper meal delivery, inadequate timeline for diaper changing, contaminants e.g. urine or feces, dehydration, poor dietary intake.

Risk Population

Highly susceptible are premature infants and those with chronic diseases including Diabetes, HIV and Down Syndrome; but any infant can succumb to Neonatal Pressure Injury as discussed above.

Associated Problems

Immediate repercussions from a pressure injury include pain. Other complications can result in paralysis, fractures, infections and even death.

Suggestions for Use

Nurses must be aware of the risk factors in order to recognize and address them promptly, when performing normal activities. Choose head elevation to keep the infant's back in contact with the bottom sheet; regularly document the developed (or loss of) pressure injury; and use air-lift mattresses or special devices where possible.

Suggested Alternative Nursing Diagnosis

• Impaired Skin Integrity: Damage to the normal textures and protective functions of the skin
• Infection Risk: Exposure of the body/areas to micro-organisms, viruses, chemicals, and other environmental factors that may cause harm
• Potential Complications of Trauma: Potential for decreases in activity, physical function and lifestyle changes due to physical or emotional trauma

Usage Tips

Although this NANDA diagnosis is designed to focus on Neonatal Pressure Injury, it can also be used with adults and aging populations.

NOC Results

• Skin Integrity: The ability to protect the external surface intact from invasion of pathogens
• Risk Control: Strategies to reduce the likelihood of an injury or risk event
• Injury Prevention: Ability to identify risk factors and eliminate or reduce hazards to prevent an injury

NIC Interventions

• Repositioning: Schedule, implement and monitor change in position of clients at intervals appropriate to condition, age and health status
• Pressure Injuries Management: Maintain tissue integrity by monitoring, preventing and managing tissue damage in response to external forces
• Skin Surveillance: Monitor the skin for changes in color, texture and temperature

Conclusion

Neonatal Pressure Injury can lead to infection and further complications if left unchecked. Early detection and proactive responses to risk factors can help protect newborns from these injuries and identify any existing problems early on.

FAQ

• What are the major risk factors for developing a neonatal pressure injury?
• Physical immaturity, obesity, increased temperatures, sliding, improper meal delivery, inadequate timeline for diaper changing, contaminants e.g. urine or feces, dehydration, poor dietary intake.
• What can nurses do to help identify and prevent neonatal pressure injury?
• Nurses must be aware of the risk factors in order to recognize and address them promptly, when performing normal activities. Choose head elevation to keep the infant's back in contact with the bottom sheet; regularly document the developed (or loss of) pressure injury; and use air-lift mattresses or special devices where possible.