00304 Risk Of Adult Pressure Injury

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: 00304
Nanda label: risk of adult pressure injury
Diagnostic focus: pressure injury
approved 2020 • Evidence level 3.4

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « risk of adult pressure injury is defined as: adult susceptible to damage located in epidermis or dermis, as a result of pressure or pressure combined with friction, which You 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
  • Inadequate availability of equipment for obese people
  • 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 activity
  • Decrease in physical mobility
  • Dehydration
  • Dry skin
  • Hyperthermia
  • Inappropriate adhesion to the incontinence treatment regime
  • Adhesion inadequate to the pressure injury prevention plan
  • Inappropriate knowledge of pressure lesions prevention strategies
  • Malnutrition in relation to proteins and energy
  • smoking
  • Inappropriate use of substances

Other factors

  • Factors identified by a standardized and validated assessment scale

Risk population

  • People in geriatric residences
  • People in intensive care units
  • People in residences of palliative care
  • People in rehabilitation residences
  • People in transit or between care residences
  • People who receive home care
  • Score ? 3 according to the classification of the physical state of the American Society of Anesthesiologists (ASA)
  • People with body mass index above the normal range according to age and sex
  • People with body mass index below the normal range according to age and sex
  • People with a history of pressure injury
  • People with physical disabilities
  • Older adults

Associated problems

  • Anemia
  • Cardiovascular disease
  • Central nervous system diseases
  • Chronic neurological problems
  • Severe condition
  • Decrease in serum albumin level
  • Decrease in tissue oxygenation
  • Decrease in tissue perfusion
  • Diabetes mellitus
  • edema
  • C-reactive protein elevation
  • Hemodynamic instability
  • Hip fracture
  • Immobilization
  • Deterioration of circulation
  • Intellectual disability
  • Medical devices
  • Peripheral neuropathy
  • Pharmacological preparations
  • Physical trauma
  • Prolonged duration of the surgical procedure
  • Sensitivity disorders
  • Spinal cord injuries