00213 Vascular Trauma Risk

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: 00213
Nanda label: vascular trauma risk
Diagnostic focus: trauma
Approved 2008 • Revised 2013, 2017 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « vascular trauma risk is defined as: susceptible to suffering an injury in a vein and surrounding tissues related to the presence of a catheter and/or the perfusion of the perfusion of solutions, which can compromise health.

Risk factors

  • Accessible place for inappropriate insertion
  • Prolonged time of permanence of the inserted catheter

Associated problems

  • Irritant solution
  • Fast perfusion pace

Suggestions of use

This is a very specific diagnosis that should only be used when a patient has a catheter inserted in the skin (for example, in peripheral roads, on the central venous line, in hemodialysis fistula). If symptoms of vascular trauma are presented, the diagnosis of tissue integrity should be used.

Suggested alternative diagnostics

  • Tissue integrity, deterioration of the

NOC Results

  • Noc results have not yet been developed for this diagnosis, although the following could be useful:
  • Hemodialysis Access: Functionality of the access site for dialysis
  • Tissue integrity: mucous skin and membranes: Structural integrity and normal physiological function of the skin and mucous membranes

Evaluation objectives and criteria

  • • Vascular trauma does not experience, as demonstrated by hemodialysis and tissue integrity access: skin and mucous membranes.
  • • Demonstrates tissue integrity: skin and mucous membranes, as manifested by the following indicators (specify from 1 to 5: severely, substantially, moderately, slightly or not compromised):
    • Skin temperature
    • Sensitivity
    • Skin integrity
  • • Demonstrates tissue integrity: skin and mucous membranes, which is manifested by the following indicators (specify from 1 to 5: severe, substantial, moderate, light or none):
    • Erythema
    • paleness
    • necrosis
    • hardening
  • Other examples

    • • bandage without leaks or moisture
    • • Absence of inflammation or discomfort
    • • Body temperature within normal limits

    NIC Interventions

    • Nic interventions have not yet been associated with the risk of vascular trauma, however, the following could be useful.
    • Medication administration: intravenous (IV): preparation and administration of medicines through an intravenous route
    • Intravenous insertion (IV): insertion of a needle into a peripheral vein, with the aim of managing liquids, blood or medications
    • Maintenance of the venous access device (DAV): maintenance of the patient with prolonged venous access by tunnelized and non -tunnelized catheters (cutaneous derivation) and implanted ports
    • Intravenous therapy (IV): Administration and control of intravenous fluids and medications (IV)

    Nursing Activities

    • Nursing activities focus on the prevention of vascular trauma (for example, by infiltration, extravasation, infection and phlebitis) and the early identification of symptoms to prevent greater complications.

    Valuations

    • • Determine the compatibility of intravenous medications and liquids before administering them
    • • Control any infiltration (inflammation, discomfort, burn, tension, cold skin, paleness)
    • • Evaluate extravasation (paleness, burn or discomfort at the intravenous road site, inflammation on the site or above it, cold skin around the site)
    • • Value site IV according to the institutional protocol
    • • (NIC) Intravenous therapy (IV)-.
      • Monitor site IV and the drip of the intravenous path during infusion
      • Monitor the permeability of the IV before administering intravenous medications
      • Monitor vital signs
      • Monitor the presence of signs and symptoms associated with infusion phlegitis and local infection

    Patient and family education

    • • Instruct the patient and the caregivers that the nursing professional should be informed if the IV does not flow or if symptoms or signs of complications occur (for example, infiltration)

    Collaboration activities

    • • Instruct the patient and the family about the procedure
    • • Follow institutional protocols and/or supplier instructions for the insertion and management of intravenous catheters (including referrals for hemodialysis and the lines inserted for hemodynamic control)

    Others

    • • Perform care at the intravenous road site according to the institutional protocol
    • • Register intake and elimination
    • • Observe the universal security measures
    • • (NIC) Intravenous therapy (IV):
      • Maintain a strict asepsis technique
      • Monitor site IV and the drip of the intravenous path during infusion
      • Replace the intravenous catheter and the mechanism, and make the infusion every 48 to 72 hours, according to the institutional protocol
      • Maintain occlusive bandage