00287 Neonatal Pressure Injury

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: 00287
Nanda label: neonatal pressure injury
Diagnostic focus: pressure injury
approved 2020 • Evidence level 3.4

NANDA Nursing Diagnosis Definition

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

Definite characteristics

  • Ampoule full of blood
  • Erythema
  • Loss of the total tissue thickness
  • Loss of the total thickness of the tissue with bone exposure
  • Loss of the total tissue thickness with muscle exposure
  • Loss of the total tissue thickness with tendon exposure
  • Local heat in relation to surrounding tissue
  • Located brown area in intact leather colorless
  • Partial loss of the thickness of the dermis
  • Purple Area Located in Intact Skin Colorless
  • Skin ulceration
  • Ulcer covered by escara
  • Ulcer covered by spherical

Related 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