NANDA-NursingPlan Area 11 Safety/Defense

NANDA-Nursing Plan 00304 Risk for adult pressure injury

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.

Area 11 Safety/defense Free from danger, bodily injury and immune system damage, protection from loss, guarantee of safety and security
Category 2 Bodily injury Bodily harm or injury

Nursing diagnosis ” Risk for adult pressure injury

Nursing Diagnosis: Risk for adult pressure injury
Definition: A condition in which the skin and underlying tissues in adults are susceptible to localized damage as a result of pressure or combined pressure and shear forces, which may impair health.

Thank you for always watching. It is often seen in older people. Let’s review together from screening to planning.

1. Indications for Nursing Diagnosis “Risk for adult pressure injury”

・screening:
・Braden scale (less than 18 points for adults)
・Braden Q scale (children below 16 points)
・ASA (American Society of Anesthesiologists) PS classification (general condition classification): 3or higher (See ✩2 below for ASA PS classification)
・Thinness, poor nutritional status, conspicuous bony protrusions
・Obesity, arteriosclerosis
·smoking
・Wet skin (wearing diapers), incontinence
・Skin thinning (edema)
・Decreased skin elasticity (decreased Turgol reaction, dehydration) See ✩3 below for Turgol reaction
・Same position for a long time, difficult to change position on one’s own
・Intraoperative positioning and fixation, postoperative rest
・Use of sedatives, paralysis,
・After orthopedic surgery (relieving the affected limb, resting, contraindicated positions)
・Body restraint
・Wrong posture change method, positioning

✩2 ASA-PS (See Wikipedia)

ASA-PS (ASA physical status) is the American Society of Anesthesiologists’ systemic status classification.
General condition is classified into 6 classes, and preoperative ASA-PS and prognosis are said to be correlated. In the case of emergency surgery, write “E” together.
In “Pressure ulcer risk condition”, class 2 or higher is judged as high risk of pressure ulcer.

✩ 3 .Turgor reaction

Use when body fluid volume decreases such as dehydration.
Pinch the skin above the forearm or sternum and release it, and if the skin returns to its original state within 2 seconds, it is judged to be normal. It takes longer than 2 seconds, and it is called a handkerchief sign that the wrinkles of the skin are slow to return.

2. aim setting

Goal setting by linkage (listed in the second half of the NOC)
* “Linkage” has the role of connecting “NANDA”, “NIC” and “NOC” (link means “connection”).

1) Linkage achievements

・Tissue integrity: skin and mucosa (1101)
(Definition: Normal physiological function without skin and mucosal tissues)
・Nutritional status: intake of nutrients (1009)
(Definition: intake of nutrients to meet metabolic needs)
・Nutritional status: biochemical test value (1005)
(Definition: biochemical indicators of body fluid composition and nutritional status)
・Sensory Function: Tactile (2400)
(Definition: ability to correctly perceive skin irritation)
・Circulatory dynamics (0401)
(Definition: the unidirectional flow of blood through the great vessels of the systemic and pulmonary circulations at normal perfusion pressure and without stagnation)
・Physical aging (0113)
(Definition: normal physiological changes that occur with natural aging)
・ Posture change: Self-power (0203)
(Definition: Movement to change position with or without assistive devices)
・ Body fluid status (0602)
(Definition: Adequate amount of intracellular and extracellular fluid in the body)
・Volume overload severity (0603)
(Definition: severity of excess intracellular and extracellular fluid)
– Urinary control (0502)
(Definition: control of urine output from the bladder)
・Defecation control (0500)
(Definition: control of defecation process)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do ○○”,
For example, “The patient will be able to do ○○.”
・Do not use dirty urine pads and replace them after excretion.
・You can take meals that are nutritionally balanced. If you have no appetite, you can consult a doctor.
・Incorporate moderate exercise into your life.
・When sleeping, you can change your position from time to time so that you do not stay in the same position for a long time.

※The goals of the nurse’s actions are as follows.
・Prevent the development of pressure ulcers by using decompression equipment, regular repositioning, and proper positioning.
・Nutritional balance is maintained to improve the health of the skin and musculoskeletal system (to prevent weight loss).
・Maintain the cleanliness of the skin and the circulation of the skin to prevent pressure ulcers from occurring due to skin problems.

3. nursing plan

1 >> Observation plan <OP>

・Automatic movement (supine, lateral, standing, sitting)
・History of pressure ulcers
・Skin temperature
・Skin sensation
・Skin elasticity ・Skin moisture content ・Skin thickness
・Body hair growth
・Abnormal pigmentation
・Skin lesions
・mucosal lesions
・Scar tissue
・Skin cancer
・Skin peeling/skin desquamation
・ Pale skin
・Calorie intake ・Protein intake ・Fat intake ・Carbohydrate intake
・Fiber intake
・Vitamin intake ・Mineral intake
・Iron intake
・Sodium intake Calcium intake
・Water intake
・Serum albumin level ・Serum prealbumin level ・Serum creatinine level
・Hematocrit value ・Hemoglobin value ・Serum transferrin value
・Discrimination of sharp stimulus ・Discrimination of dull stimulus ・Discrimination between two points
・Identification of vibration
・Temperature identification
・Pressure identification
・Dysparesthesia/Loss of sensation
・numbness
・Blood pressure ・Pulse pressure ・Mean blood pressure ・Central venous pressure ・Distention of the jugular vein
・PaO2・PaCO2・Oxygen saturation
・Urine volume
・Capillary filling time
・Vascular murmur ・Heart murmur
・Peripheral edema
・Weight gain ・Ascites ・Fatigue
・Skin temperature drop ・Sensory abnormality
・syncope
・Pilt edema
・Lower leg ulcers
・ Decrease in body fluid volume
・Skin elasticity
・Depletion of cells
・Bone density
・Basal metabolic rate
・Fat distribution pattern ・Muscle strength ・Range of motion
・diarrhea
・Periorbital edema ・Limb edema ・Sacral edema
・Ascites/weight gain
・Generalized edema
・Pulmonary murmurs (bubbles)
〈Urination control〉
→ Skin maceration/skin disorder due to urinary incontinence
・Urinary pattern ・Urinary urge
・Volume of urine per urine ・Feeling of residual urine ・Residual urine
・urinary incontinence
・Wearing diapers
・Water intake
・Defecation pattern ・Defecation urge
・Stool condition (diarrhea)
・Water intake
・Tube feeding
・Lactose intolerance (inappropriate for tube feeding)
・Fecal incontinence ・Wearing diapers
・Use of antibiotics (risk of diarrhea due to bacterial replacement)
・Use of anticancer drugs (molecular target drugs, immune checkpoint inhibitors, irinotecan, etc.)

2 》 Action plan 《TP》

・The content and form of meals should be devised so that the necessary amount of food intake can be secured.
・In the case of nutritional deficiencies, supplementary foods should be considered.
・Perform appropriate positioning. (especially avoid compressing bony prominences)
・Change positions regularly. If it is possible to change the body position on its own, talk to it regularly.
・If you are sitting in a wheelchair for a long time, use a pressure-resistant cushion and periodically call out to relieve the pressure.
・If you are bedridden, consider using an air mattress.
・Use the dehumidification mode and automatic intercourse mode of the air mattress.
・Measure body weight regularly.
・If there is edema, perform drainage and massage.
・If you cannot make it to the toilet in time and are incontinent, consider using a urinal or portable toilet.
・When wearing diapers, clean the pubic area.
・If the baby has diarrhea, change diapers frequently.
・Consult a doctor if you have diarrhea due to starting tube feeding. (Consider changing nutritional supplements)
・Consult a doctor if you have diarrhea due to the start of antibiotics. (Consider intestinal and antidiarrheal agents)
・Consult a doctor if diarrhea occurs due to anticancer drugs. (Antidiarrheal agents may be considered, or fluid replacement may be considered in the case of anticancer drugs for which antidiarrheal agents cannot be used.)
• Keep warm if obliteration circulation is not maintained. (hot water bottle, hanging, room temperature)
・If there is edema, pay attention to postural changes. (Avoid skin breakdown)
・Affix a film dressing to reinforce skin peeling and subcutaneous bleeding due to fragility of the skin. Water-repellent petroleum jelly is applied to areas where it is difficult to apply the film to protect the subcutaneous tissue from irritation (make it act like an epithelium).
・Understand the urination pattern and defecation pattern, and guide the patient to the toilet before urinary or fecal incontinence occurs.

3 >> Education plan 《EP》

・If you feel the urge to urinate or defecate, tell the patient to call the nurse.
・Explain that if you incontinence, don’t be shy and call the nurse. (Explain the need for a nurse call if long-term adhesion of waste causes skin problems.)
・Teach them to eat a well-balanced diet.
・Instruct the patient not to stay in the same position for a long time and to release the pressure occasionally.
・Explain to let them know if they have numbness, paresthesia, or swelling.
・Explain that if diarrhea occurs due to the use of antibiotics or anticancer drugs, the patient should be notified.
・Explain not to hit the swollen part.

References

NPO Japan Society for Medical Social Work. (2020). Medical Welfare Comprehensive Guidebook. Igaku Shoin.
T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008). Nursing Learning Dictionary (3rd Edition). Gakken Co., Ltd. (Gakken).
Takeda, Nobuko. (2010, 5th edition). Systematic Nursing Course, Separate Volume, Rehabilitation Nursing. Igaku Shoin.

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