00313 Pressure Injury In The Child

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: 00313
Nanda label: pressure injury in the child
Diagnostic focus: pressure injury
approved 2020 • Evidence level 3.4

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « pressure injury in the child is defined as: damage located in epidermis or dermis of a child, 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
  • Pain at pressure points
  • Partial loss of the thickness of the dermis
  • Purple Area Located in Intact Skin Colorless
  • Ulcer covered by escara
  • Ulcer covered by spherical

Related factors

External factors

  • Microclimate alteration between the skin and the support surface
  • Difficulty of the caregiver (a) to lift the patient completely from the bed
  • Excessive humidity
  • Inappropriate access to appropriate equipment
  • Inappropriate access to appropriate health services
  • Inappropriate access to appropriate accessories
  • Inadequate access to equipment for children with obesity
  • 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 activity
  • Decrease in physical mobility
  • Dehydration
  • Difficulty in helping the caregiver (a) to mobilize
  • Difficulty to keep the position in bed
  • Difficulty to maintain the position in the chair
  • Dry skin
  • Hyperthermia
  • Inappropriate adhesion to the incontinence treatment regime
  • Adhesion inadequate to the pressure injury prevention plan
  • Inappropriate knowledge about appropriate methods to remove adhesive material
  • Inappropriate knowledge about appropriate methods to stabilize devices
  • Malnutrition in relation to proteins and energy
  • Electrolytes-water imbalance

Other factors

  • Factors identified by a standardized and validated assessment scale

Risk population

  • Children in intensive care units
  • Children in long -stay residences
  • Children in palliative care residences
  • Children in rehabilitation residences
  • Children in transit or between care residences
  • Children who receive home care
  • Children with body mass index above normal range according to age and sex
  • Children with body mass index below the normal range according to age and sex
  • Children with development problems
  • Children with growth problems
  • Children with large cranial circumference
  • Children with large body area

Associated problems

  • pH of alkaline skin
  • Altered cutaneous structure
  • Anemia
  • Cardiovascular disease
  • Decrease in the level of consciousness
  • Decrease in serum albumin level
  • Decrease in tissue oxygenation
  • Decrease in tissue perfusion
  • Diabetes mellitus
  • edema
  • C-reactive protein elevation
  • Frequent invasive procedures
  • Hemodynamic instability
  • Immobilization
  • Deterioration of circulation
  • Intellectual disability
  • Medical devices
  • Pharmacological preparations
  • Physical trauma
  • Prolonged duration of the surgical procedure
  • Sensitivity disorders
  • Spinal cord injuries