INTRODUCTION
Chronic wounds are a serious public health problem because they harm people's physical and emotional integrity and quality of life. Complex wounds (CF) are prevalent according to conditions and etiologies, such as ulcers resulting from arterial disease, venous insufficiency, mixed ulcers, pressure ulcers, and ulcers resulting from metabolic diseases, such as diabetes mellitus, whose common characteristic is poor perfusion(1). CF is defined as any wound that does not heal within six weeks with properly guided therapy. The line of care for chronic wounds should not only be based on practice focused on wound treatment, but also follow a treatment plan that encompasses a triad: assessment of the patient, the etiology of the chronic wound, and local treatment, considering the patient as a person(2). Therefore, a chronic wound requires specific daily care and subsequent recording, in order to verify the evolution during the healing process.
In order to improve patient care in the health network, processes were created for nursing services, thus assisting activities in stages; this process is called Nursing Care Systematization(3). Thus, one of the SAE processes is based on identifying nursing diagnoses aimed at the individual needs of each patient. The nursing diagnosis profile added to the standardized dialect facilitates the management of patient resources in addition to supporting nursing interventions. Based on the definition of scientific facts in the field of nursing, the objective is to provide continuing education, professional identity, contribute to the management of resources and people, in addition to supporting appropriate nursing interventions(4).
In this way, identifying the main nursing diagnoses presented by people with CF being followed in a line of care can support nursing care based on individual needs with the elaboration of a unique therapeutic plan, which would help the nursing professional to conduct interventions in a timely manner and monitor the evolution of the clinical condition through clinical judgment(5).
To this end, it is necessary to use a classification system that standardizes nursing diagnoses, such as the North American Nursing Diagnosis Association Classification 2021-2023 (NANDA), which brings together 267 nursing diagnoses reviewed and approved by the Diagnostic Development Committee (DDC). According to NANDA (2021), the initial assessment of the patient involves collecting subjective and objective data and a review and analysis of information from the patient's history. In this context, nursing consultation and follow-up of people with CF are opportune moments to identify the most relevant nursing diagnoses for each patient and the similarities between them, thus contributing to the planning of the care provided to the patient.
In view of this, this study aims to map the nursing diagnoses identified by nurses in the follow-up of people with difficult-to-heal wounds in follow-up care at a basic health unit in Macapá-AP.
METHODS
This is a descriptive study with a quantitative approach. The sample was non-probabilistic for convenience, that is, non-random, of patients being followed up in the line of care for people with chronic wounds at the Basic Health Unit (UBS) of the Federal University of Amapá (UNIFAP) and treated by the chronic wound management team (TIGESFC). The eligibility criteria were: people with difficult-to-heal wounds being followed up in the line of care for wounds at the UBS/UNIFAP, over 18 years old, of both sexes and who were able to understand and answer the questions, were physically capable of participating in the nursing consultation, and consented to participate in the study. This study was authorized by the management of the basic health unit and was approved by the Research Ethics Committee of the Federal University of Amapá under opinion No. 4,280,682. Data collection was carried out from March to May 2023, as follows: first, contact was made with people with complex wounds treated by TIGESFC and an invitation was made to participate in the study. If accepted, a nursing consultation was scheduled in which the data collection instrument consisting of patient identification (initials of name, age, sex, and ethnicity), clinical data (comorbidities and type of wound), anamnesis form, and physical examination was applied. Subsequently, based on clinical judgment, the diagnostic titles were mapped by cross-mapping the terms and expressions with the defining characteristics, related factors, risk factors, and nursing diagnosis titles approved by the NANDA-I classification.
The collected data were tabulated using Microsoft Excel for Windows 2016 ® and analyzed with the aid of the statistical software Statistica® 9.0, establishing absolute and relative frequency measures for all analyzed data.
RESULTS
The study consisted of a sample of 17 people with CF who were being followed up in the line of care for people with chronic wounds at UBS/UNIFAP. The results will be described in sociodemographic variables, clinical variables and the prevalence of nursing diagnoses.
The sociodemographic characteristics analyzed in this study were sex, age and ethnicity, which are described in absolute and relative frequency in Table 1.
Table 1 - Sociodemographic variables of patients with difficult-to-heal wounds
|
Variable |
Category |
N |
% |
|
Gender |
Female Male |
4 13 |
23,6% 76,4% |
|
Age Range |
30-40 years old 41-50 years old 51-60 years old 61-70 years old |
4 4 5 4 |
23,5% 23,5% 29,5% 23,5% |
|
Ethnicity |
White Brown Black Not Declared |
2 10 2 3 |
11,7% 59% 11,7% 17,6% |
Source: The authors, 2024.
Of the 17 people with chronic wounds who participated in this study, the prevalence of males (76.4%) was noted, with the predominant population undergoing treatment for difficult-to-heal wounds. Regarding the age group, the average age attended was 51.5±11.6 years, with a lower limit of 31 years and an upper limit of 70 years, with a predominance of the 51-60 year-old population (29.5%), and a more homogeneous distribution for the other age groups of 30-40 years, 41-50 years and 61-70 years, around 23.5%.
As for the ethnicity variable, there was a prevalence of mixed race patients (59%), in addition, there was a significant percentage of undeclared patients (17.6%). In another point, the results obtained from the clinical variables stand out, being delimited by the existing comorbidity and the type of wound. Table 2 presents these data.
Table 2 - Clinical variables of patients with difficult-to-heal wounds
|
Variable |
Category |
N |
% |
|
COMORBIDITY
|
DM2 DM2+HAS VENOUS INS. |
9 6 1 |
52,9% 35,2% 5,8% |
|
TYPE OF WOUND |
UPD MIXED ULCER UV TRAUMA |
14 1 1 1 |
82,3% 5,8% 5,8% 5,8% |
* DM2: Type 2 Diabetes Mellitus; SAH: Systemic arterial hypertension; UPD: Diabetic foot ulcer; UV: Venous ulcer.
Source: The authors, 2024.
Regarding comorbidity, there was a higher prevalence of people with type 2 Diabetes Mellitus (52.9%), associated with a metabolic disorder that can be characterized by hyperglycemia and deficit in carbohydrate metabolism. In addition, there was an association of two chronic conditions, DM and hypertension, with 35.2%. The results found in Table 2 highlight a lower percentage compared to the other comorbidities presented in the study, approximately 5.8% of the total number of patients mapped.
In Diabetic Foot Ulcers (DFU), it was identified that 82.3% of the individuals evaluated had been diagnosed with this type of wound. Mixed ulcers demonstrated one of the lowest incidences when it comes to the type of wound, with 5.8% of the known etiologies identified. During the study mapping, it was identified that only 5.8% of the patients were affected by this chronic wound.
Subsequent to mapping nursing diagnoses, it is pertinent to develop some of them, based on their frequency and their relationship with difficult-to-heal wounds. Thus, after cross-mapping the terms and expressions collected during the anamnesis and physical examination of people with chronic wounds, the presence of defining characteristics and related factors that supported the titles of nursing diagnoses contained in NANDA-I was verified. Thus, in the sample studied, it was possible to identify a total of 68 nursing diagnoses in patients with chronic wounds, with 19 different diagnoses, which are listed in Table I.
Table I - Nursing diagnoses found in people with chronic wounds
|
|
Nursing diagnosis |
N |
(%) |
|
1 |
Impaired skin integrity |
17 |
25 |
|
2 |
Risk of infection |
7 |
10,29412 |
|
3 |
Impaired comfort |
5 |
7,352941 |
|
4 |
Impaired walking |
5 |
7,352941 |
|
5 |
Ineffective peripheral tissue perfusion |
4 |
5,882353 |
|
6 |
Risk of unstable blood glucose |
4 |
5,882353 |
|
7 |
Unbalanced nutrition |
4 |
5,882353 |
|
8 |
Ineffective self-management of health |
4 |
5,882353 |
|
9 |
Deficient knowledge |
3 |
4,411765 |
|
10 |
Impaired physical mobility |
3 |
4,411765 |
|
11 |
Social isolation |
2 |
2,941176 |
|
12 |
Body Image Disturbance |
2 |
2,941176 |
|
13 |
Readiness to improve health literacy |
2 |
2,941176 |
|
14 |
Readiness for improved health self-management |
1 |
1,470588 |
|
15 |
Situational risk of low self-esteem |
1 |
1,470588 |
|
16 |
Readiness for enhanced self-management of health |
1 |
1,470588 |
|
17 |
Hopelessness |
1 |
1,470588 |
|
18 |
Chronic pain |
1 |
1,470588 |
|
19 |
Risk for frail elderly syndrome |
1 |
1,470588 |
|
|
TOTAL |
68 |
100 |
Source: The authors, 2024.
In Table I, the most frequent ND is “impaired tissue integrity” with a percentage of 25%. Consequently, the ND “risk for infection” is presented with an index of 10.29412%. Furthermore, the diagnosis of “ineffective peripheral tissue perfusion” was obtained with a frequency of 5.882353%, listing the diagnoses “impaired comfort” and “impaired walking”, both with a frequency of 7.352941%.
In addition, with a frequency of 5.882353%, the diagnosis of risk of “unstable glycemia” was found, and one of the diagnoses present and that influences difficult-to-heal wounds is “imbalanced nutrition” with a frequency of 5.882353%.
Other diagnoses present in this study, but with less frequency: “Ineffective health self-management” (5.882353%); “Deficient knowledge” (4.411765%); “Impaired physical mobility” (4.411765%); “social isolation” and “body image disturbance” (2.941176%); “Readiness to improve health literacy” (2.941176%).
Finally, the diagnoses of “risk for situational low self-esteem”, “hopelessness”, “chronic pain”, “risk for frail elderly syndrome”, “readiness for improved health self-management” and “readiness for improved health self-management” appear with a frequency of 1.47%.
DISCUSSION
Epidemiological data show that for every three people who die in Brazil, two are male, accounting for approximately 60% of deaths in the country. From this, it can be inferred that the process of illness in men causes more complications than in women, since the search for preventive measures in basic health units is predominantly carried out by women. Therefore, the search for care by the male class mostly arises from the onset of pathology(6).
Table 1 shows the presence of young adults, full adults and elderly people, i.e. chronic wounds are present in all age groups of adult life(7). However, according to data from the National Health Survey conducted by IBGE in 2013, 40% of the Brazilian adult population has at least one chronic disease, the most recurrent being, respectively, diabetes, cardiovascular diseases, cancers and circulatory pathologies(8). Based on research and databases, it is possible to observe an increase in the number of people becoming ill, with an increasingly younger class being affected by chronic diseases and, consequently, by injuries that are difficult to heal.
In the northern region, there is a prevalence of self-declared brown ethnicity; according to the IBGE, in 2021, the percentage of the brown population in the northern region of the country was 73.4% (9). Care for people with wounds that are difficult to heal is not limited to the physiological aspects of the wound; nurses must direct their attention to the individual as a whole. Therefore, it is necessary for professionals to seek to use techniques that can support adequate care. In view of this, outlining the profile of the population that seeks health services helps nurses to set goals and consider strategies for health promotion, including preventive measures and adherence to treatment and its continuity.
Thus, it can be said that the prevalence of DM in Central and South American countries was estimated at 26.4 million people and projected to reach 40 million by 2030. In developing countries, this increase will occur in all age groups, with the prevalence tripling in the 45 to 64 age group and doubling in the 20 to 44 and over 65 age groups(10). Therefore, Brazil, being a developing country, tends to have an increasing number of people with DM in all age groups, confirming its prevalence in this study.
Considering that the emergence of DM has SAH as a risk factor(11), it is therefore understood that individuals with systemic arterial hypertension have a greater risk of developing diabetes mellitus.
Venous insufficiency (VI) is defined as a dysfunction of the venous system caused by valve problems related or not to obstruction of venous blood flow. Acute venous insufficiency can cause problems in the superficial venous system or the deep venous system or both. It can also be the result of a congenital or acquired disorder(12).
Despite the low percentage, it is estimated that 5 to 30% of the adult population presents symptoms or signs of VI, which is considered a serious public health problem(13).
There are several known etiologies of lower limb ulcers, with venous origin being the most frequent in 70% of cases, followed by arterial origin in 10% to 20% of cases and mixed etiology in 10 to 15% of cases(14).
Diabetic foot involves a series of pathophysiological processes ranging from infection to ulceration with subsequent deep tissue destruction, neurological abnormalities and/or vascular involvement that causes suffering, disability and absence from work for the individual(15). However, a study conducted in Family Health Units evaluated 47 people with chronic wounds and only 8.5% of this number had diabetic foot ulcers(4).
It is known that mixed ulcers are caused by a combination of chronic venous hypertension and peripheral arterial disease; ulceration has mixed characteristics because it is caused by venous and arterial diseases(16).
In Brazil, isolated studies such as one conducted in Minas Gerais, southeastern Brazil, observed that mixed ulcers have a lower prevalence than the others, demonstrating approximately 2% of the total of 57 people, corroborating the findings of this study(17).
Venous ulcers (VU) are defined as chronic lesions that develop between the ankle region and the middle third of the leg due to persistent venous hypertension. This condition results in reduced diffusion of nutrients and oxygen, creating a favorable microenvironment for the emergence of these lesions(18). However, a study found that 52% of the patients evaluated in the study were affected by venous ulcers(17).
Physical trauma is considered a risk factor for those with chronic wounds and is associated with other clinical complications that hinder wound healing(19). The results in Table 2 suggest that only 5.8% of the individuals had the type of wound based on some trauma. Another study analyzed patients from an outpatient clinic in Chapecó-SC, and only 13% of them had some type of wound based on traumatic injury(20). However, another study evaluated 27 patients in a health unit in Goiás, and it was found that 97% of the wounds were related to trauma(21).
The use of specific terminology in nursing, through the classification of Nursing Diagnoses of NANDA International (NANDA-I), is essential to develop care for individuals with CF(22).
One of the main functions of the skin is to cover the body, and it constitutes an integral defensive barrier that isolates the internal structures from the external environment(23). When this integrity is discontinued, imbalances and health problems can occur, and consequently, wounds. Therefore, this diagnosis was identified in all participants, since they are being monitored. According to NANDA, one of the associated conditions that were characteristic of the research were metabolic diseases and cardiovascular diseases, as previously mentioned, diabetes mellitus and systemic arterial hypertension. DM is the main cause of the emergence of diabetic foot ulcers, and the lack of control of blood glucose levels affects circulation, which contributes to the formation of ulcers(24).
According to NANDA, the risk of infection is characterized by the susceptibility of invasion and multiplication of pathogenic organisms, which can compromise health. One of the risk factors associated with this diagnosis is the integrity of the broken skin itself, facilitating the entry of microorganisms and bacteria, also associated with increased environmental exposure to pathogens. With the associated conditions, the presence of a suppressed inflammatory response was observed. Chronic diseases bring consequences, one of which is secondary immunodeficiency, which affects the immune system and consequently increases vulnerability to infections(25).
Ineffective peripheral tissue perfusion can be understood as the reduction of blood circulation to the periphery. In the context of wounds, the absence of circulation or its impairment in the peripheral region of the body can cause health risks, since the peripheral zone is where wounds are most affected. It was possible to perceive delayed peripheral wound healing, edema and decreased peripheral pulses as defining characteristics, with inadequate knowledge about the disease as a related factor, as well as a sedentary lifestyle. However, the associated conditions present were diabetes mellitus and hypertension. The lack of control of blood glucose levels affects circulation, which contributes to the formation of ulcers. The areas at greatest risk are the toes, the grooves between them, and the medial and distal regions(24).
Impaired walking, on the other hand, has as defining characteristics difficulty in walking the necessary distances and difficulty climbing stairs, with factors related to pain, insufficient muscle strength, and in some patients obesity. Associated conditions include impaired postural balance. For impaired comfort, anxiety, discomfort with the situation, expression of discomfort, and irritable mood are observed as defining characteristics, as well as associated conditions related to the treatment regimen and symptoms related to the disease. Foot ulcers are documented as precedents in approximately 85% of all diabetic amputations. In most cases, amputation had to be performed due to the combination of deep infection and ischemia(24). In view of this, it is observed that in this context, these two nursing diagnoses emerge from an amputation, which can cause both difficulty in walking and impair the comfort of that patient.
Diabetes was the most frequent comorbidity, and most patients being monitored have this risk, which can be defined as inadequate adherence to the treatment regimen or inadequate self-management of diabetes, with diabetes itself as an associated condition. Thus, in this scenario, it is possible to observe the variation of serum glucose levels in relation to the normal range. One of the factors that delay the healing of chronic wounds is the non-physiological inflammatory response. This type of wound usually stagnates in the inflammatory phase, delaying the formation of granulation tissue. Hyperglycemia is one of the causes that contributes to the return of the inflammatory response and thus impairs the functions of neutrophils, macrophages and lymphocytes(26).
The defining characteristics of an unbalanced nutrition are delayed wound healing and factors related to inadequate food supply. The assessment of a wound and its healing require a range of factors to be assessed, one of which is nutritional status, given that it is on the list of systemic factors that affect the body and hinder healing. Proteins are essential for all aspects of healing, from collagen synthesis and epidermal proliferation to neovascularization(27).
Furthermore, ineffective self-management of health is defined as the exacerbation of disease symptoms and sequelae of the disease as defining characteristics, and factors related to inadequate commitment to an action plan and consequently non-acceptance of a condition. In these cases, clients enter into denial, especially in relation to amputations. Deficient knowledge, with imprecise statements on a subject, inappropriate behavior and imprecise following of instructions, related to inadequate or incorrect information. Impaired physical mobility involves altered gait, uncoordinated or slow movements followed by an expression of discomfort, related to decreased muscle strength and decreased muscle control and associated conditions such as altered integrity of bone structures and altered metabolism. In addition, isolation can occur through this image disorder, related to a missing body part that can apparently alter physical appearance, with factors related to low self-esteem, inadequate social support and impaired physical mobility, associated with chronic pain, wounds and injuries and the treatment regimen. For Readiness to improve health literacy, its defining characteristic is based on the desire to improve the understanding of health information.
Among the less frequent diagnoses, it is worth highlighting that the diagnosis of risk for situational low self-esteem is related to the diagnosis of body image disorder. Chronic pain was characterized by intense reports of pain related to social isolation and fatigue, with the condition associated with soft tissue injuries. The risk of frail elderly syndrome is associated with inadequate social support, decreased muscle strength and impaired postural balance linked to associated conditions of chronic disease. Furthermore, it is important to emphasize the presence of diagnoses in the health promotion domain that demonstrate that the person is maintaining a satisfactory pattern of symptom management, therapeutic regimen and physical consequences characterized by an expression of a desire to improve commitment to follow-up care.
CONCLUSIONS
The objective of the study was achieved, and it was possible to map the nursing diagnoses of people with difficult-to-heal wounds. The results indicated a predominance of males, with an average age of 51.5 years, predominantly of mixed ethnicity. The majority were diabetic and the main chronic wound was the diabetic foot ulcer.
The data collection allowed for the cross-mapping of terms and expressions identified during the anamnesis and physical examination with the standardized classification of nursing diagnoses of NANDA-I. In total, 68 nursing diagnoses were identified, 19 of which were different.
It is noteworthy that a greater number of nursing diagnoses related to impaired skin integrity was observed, as well as infection risks in different domains of NANDA-I and also a link between comprehensive management in the provision of care based on clinical, systematic protocols, evidence and records, promoting a nursing approach that will result in improvements in the quality of life of individuals and professional prestige in the promotion of health products and technologies, which will contribute to nursing practice.
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Funding and Acknowledgements
This work was carried out with the support of the Department of Extension – DEX/ Pro-Rectory of Extension and Community Actions - Proeac of the Federal University of Amapá (Unifap) in Macapá, Amapá, Brazil, with internal funding through Notice 03/2022 – DEX/Proeac – scholarships and financial aid to researchers at DEX/Proeac under code PJ043-2022, with a scholarship for academics Larissa Laila Paiva Lobato and Huelem Laís Cristo Teixeira.
Authorship criteria (authors' contributions)
Larissa Laila Paiva Lobato: Methodology, Investigation, Validation, Formal analysis, Visualization, Writing – preparation of the original draft. Huelem
Laís Cristo Teixeira: Methodology, Investigation, Validation, Formal analysis, Visualization, Writing – preparation of the original draft.
Karoliny Miranda Barata: Investigation, Validation, Formal analysis, Visualization, Writing.
Cecília Rafaela Salles Ferreira: Investigation, Validation, Formal analysis, Visualization, Writing – Review and Editing.
Francineide Pereira da Silva Pena: Investigation, Validation, Formal analysis, Visualization, Writing – Review and Editing.
Walter de Souza Tavares: Conceptualization, Project administration, Investigation, Methodology, Visualization, Resources, Fundraising, Supervision, Writing – Review and Editing. Conflict of interest statement Nothing to declare
Scientific Editor: Ítalo Arão Pereira Ribeiro. Orcid: https://orcid.org/0000-0003-0778-1447
Rev Enferm Atual In Derme 2025;99(1): e025022
Atribuição
CCBY