00288 Risk Of Neonatal Pressure Injury

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: 00288
Nanda label: risk of neonatal pressure injury
Diagnostic focus: pressure injury
approved 2020 • Evidence level 3.4

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « risk of neonatal pressure injury is defined as: neonate susceptible to damage located in epidermis or dermis, as a result of pressure or pressure combined with friction, which can compromise Health (European Pressure Ulcer Advisory Panel, 2019).

Risk factors

External factors

  • Microclimate alteration between the skin and the support surface
  • Excessive humidity
  • Inappropriate access to appropriate equipment
  • Inappropriate access to appropriate health services
  • Inappropriate access to appropriate accessories
  • Inappropriate knowledge of the caregiver (a) about the appropriate methods to remove adhesive material
  • Inappropriate knowledge of the caregiver (a) about the appropriate methods to stabilize the devices
  • Inappropriate knowledge of the caregiver (a) about the modifiable factors
  • Inappropriate knowledge of the caregiver (a) about pressure injury prevention strategies
  • Increase in the magnitude of the mechanical load
  • Bone prominence pressure
  • Hear forces
  • Friction on the surface
  • Sustained mechanical load
  • Use of bedding with insufficient moisture absorption capacity

Internal factors

  • Decrease in physical mobility
  • Dehydration
  • Dry skin
  • Hyperthermia
  • Electrolytes-water imbalance

Other factors

  • Factors identified by a standardized and validated assessment scale

Risk population

  • Infants with low birth weight
  • Neonates <32 weeks of gestation
  • Neonates who experience prolonged stays in intensive care units
  • Neonates in intensive care units

Associated problems

  • Anemia
  • Decrease in serum albumin level
  • Decrease in tissue oxygenation
  • Decrease in tissue perfusion
  • edema
  • Immature skin integrity
  • immature skin texture
  • Immature corneal layer
  • Immobilization
  • Medical devices
  • Nutritional deficiencies related to prematurity
  • Pharmacological preparations
  • Prolonged duration of the surgical procedure
  • Significant comorbidity