00087 Perioperative Postural Injury Risk

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: <00087
Nanda label: risk of perioperative postural injury
Diagnostic focus: perioperative postural injury
Approved 1994 • Revised 2006, 2013, 2017, 2020 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « risk of perioperative postural injury is defined as: susceptible to anatomical and accidental physical changes as a result of the position or positioning of the equipment used during a surgical/surgical procedure/ invasive, that can compromise health.

Risk factors

  • Decrease in muscle strength
  • Dehydration
  • Factors identified by a standardized and validated assessment scale
  • Inappropriate access to appropriate equipment
  • Inappropriate access to appropriate support surfaces
  • Inadequate availability of equipment for obese people
  • Malnutrition
  • Obesity
  • Prolonged non -anatomical position of the limbs
  • Rigid support surface

Risk population

  • People with extreme ages
  • People in lateral position
  • People in lithotomy position
  • People in prona position
  • People in Trendelenburg position
  • People who suffer surgical intervention> 1 hour

Associated problems

  • Diabetes mellitus
  • edema
  • Emaciation
  • General anesthesia
  • Immobilization
  • Neuropathy
  • SENSORYPECTIVE ALTERATIONS DUE TO ANESTHESIA
  • Vascular diseases

Suggestions of use

This diagnosis is a specific variation of risk of injury. All surgical patients have at least a certain risk of transoperative postural injury (LPT). People who do not have pre -existing risk factors do not require an etiology, since the transoperative posture itself is the etiology. When there are previous risk factors (for example, edema, advanced age, diabetes, arthritis, vascular disease), should be included as etiology (for example, risk of LPT related to generalized edema). A prolonged surgical procedure also increases the risk of LPT. Transoperative postural lesion may be the etiology of other nursing diagnoses (for example, deterioration of skin integrity).

Suggested alternative diagnostics

  • Peripheral neurovascular dysfunction, risk of
  • Cutaneous integrity, risk of deterioration of
  • Tissue integrity, risk of deterioration of
  • Trauma, risk of

NOC Results

  • To evaluate the real presence of transoperative postural injury, the following result should be used:
  • Severity of physical injury: severity of injuries caused by accidents and trauma
  • The following are some results related to risk factors for transoperative postural injury:
  • Circulatory status: Unidirectional blood flow without obstacles, with adequate pressure, through the large vessels of systemic and pulmonary circuits
  • Tissue perfusion: cell phone: sufficiency of the blood flow of the vasculature to maintain the function at the cellular level
  • Tissue perfusion: peripheral: sufficiency of blood flow of small limb vessels to maintain tissue function
  • Recovery after a procedure: degree to which an individual recovers its original operation after the application of procedures that require anesthesia or sedation

Evaluation objectives and criteria

  • There is no transoperative postural lesion LPT, as evidenced by a circulatory state without compromise and a good level of tissue perfusion: cell phone and peripheral.
  • Demonstrates circulatory state, as manifested by the following indicators (specify from 1 to 5: severe, substantial, moderate, mild or without deviation from normal limits):
    • Pedic, femoral, radial and humeral (bilateral)
    • Systolic and diastolic blood pressure
  • Other examples

    The patient will present:

    • No cutaneous, tissue or neuromuscular injury, as a result of a transoperative posture
    • Active capillary reflux
    • Normal peripheral sensitivity
    • Normal cutaneous temperature and color
    • Muscle function without deterioration
    • Without peripheral edema
    • No pain located in the limbs

    NIC Interventions

    • Nursing interventions focus on preventing postural injuries.
    • Change of position: Transoperative: Movement of the patient or some part of his body to allow surgical exposure, as long as the risk of discomfort and complications is reduced
    • Pressure management: reduce the pressure in different areas of the body as much as possible
    • Peripheral sensitivity management: prevention or decrease in injuries or discomfort of patients with sensitivity alteration
    • Circulatory prevention: protection of an area located with limited perfusion
    • Skin surveillance: Patient data collection and analysis to maintain the integrity of the skin and mucous membranes

    Nursing Activities

    Valuations

    • Determine the pre -existing factors (poor nutrition, diseases) that constitute a risk of LPT
    • (NIC) Change of position: Transoperative:
      • Determine the degree of mobility and stability of patient joints
      • Check peripheral circulation and neurological state
      • Monitor the patient’s posture in the transoperative
    • (NIC) Skin surveillance (Postoperative period):
      • Monitor color, temperature, inflammation, pulse and extremities texture, as well as the presence of edema and ulcers
      • Monitor the presence of areas with discoloration, bruises and breaks in the skin
      • Monitor the temperature and skin color

    Patient and family education

    • (NIC) Skin surveillance: instruct the family member or caretaker on the skin break signals, if so requires

    Collaboration activities

    • Inform during the transfer to the possesthesia nursing professional about any pre -existing risk factor or symptoms observed during surgery and immediate postoperative recovery

    Others

    • Raise the patient when changing it; Do not drag or push it
    • Change to the patient always slowly and gently
    • Make sure that the members of the surgical team do not rely on the patient
    • (NIC) Change of position: Transoperative:
      • Use auxiliary devices (for example, leg clamping strip) for immobilization
      • Use a suitable number of people to transfer the patient
      • Hold the head and neck during the transfer
      • Protect venoclysis lines, catheters and respiratory tubes
      • Keep the body of the patient correctly aligned (see institutional procedures or a surgery book, to obtain information on supine, prone, lateral and gynecological positions)
      • Raise the limbs, as required
      • Place pads (for example, in bone prominences) or avoid pressure in superficial nerves
      • Place a safety strip and a subjection of the arms, as needed
      • Protect the eyes, as required

    Older people

    • Be special care in avoiding pressure in bone prominences; Older people are vulnerable to tissue damage due to the loss of subcutaneous fat, muscle weakening and nutritional deficit