Figure 1
- First assessment, recorded before debridement. Salvador, Bahia, March 10,
2021.
![](3D"1095EVOLUTIONOFPRESSUREtraduzidoHTMLEN_arquivos/image002.gif")
Source: Own
authorship
EVOLUTION
OF PRESSURE INJURY ASSOCIATED WITH CONSERVATIVE INSTRUMENTAL BREAKDOWN BY
NURSES IN PRIMARY HEALTH CARE
EVOLUÇÃO
DE LESÃO POR PRESSÃO ASSOCIADA AO DESBRIDAMENTO INSTRUMENTAL
CONSERVADOR PELA ENFERMEIRA NA ATENÇÃO PRIMÁRIA &Agrav=
e;
SAÚDE
Lilia Conceição Sales Bernardino<=
span
style=3D'font-family:"Times New Roman",serif;color:black'>[1]<=
span
style=3D'mso-bookmark:_Hlk75624624'> * Ivaldina Nascimento Braga dos Santos<=
span
style=3D'font-family:"Times New Roman",serif;color:black'>[2]<=
span
style=3D'mso-bookmark:_Hlk75624624'> * Fernanda Matheus Estrela[3] * Caroline Fernandes Soares e Soares<=
span
style=3D'font-family:"Times New Roman",serif;color:black'>[4]<=
span
style=3D'mso-bookmark:_Hlk75624624'> * Giovana da Mata Bina[5] * Renata Pacheco Reis[6] * Daniela Fagundes de Oliveira<=
span
style=3D'font-family:"Times New Roman",serif;color:black'>[7]<=
span
style=3D'mso-bookmark:_Hlk75624624'> * Amanda Cibele Gaspar Santos<=
span
style=3D'font-family:"Times New Roman",serif;color:black'>[8]<=
span
style=3D'mso-bookmark:_Hlk75624624'> * Rose Ana Rios David<=
span
style=3D'font-family:"Times New Roman",serif;color:black'>[9]<=
span
style=3D'mso-bookmark:_Hlk75624624'> * Nayara da Silva Lima[10]<=
![endif]>
ABSTRACT
Objective: to describe=
the
successful experience of treating a pressure injury using conservative
instrumental debridement technique by the Primary Health Care nurse associa=
ted
with treatment with special coverings. Methodology: this is a
descriptive, exploratory, qualitative research, of the type case study of a
patient with a complex wound. Held at USF Alto de Coutos 2, in the Suburban
Railway Health District in the city of Salvador, Bahia. The data collected
through observation, interview and analysis of medical records throughout t=
he
treatment. The ethical aspects of the National Health Council and the resea=
rch
approved by the Ethics Committee of the Federal University of Bahia were
respected. Results: The patient presented a pressure lesion in the
sacral region, covered by coagulation necrosis. Conservative instrumental
debridement of the necrotic tissue was performed, without bleeding or other
complications, associated with treatment with special coverings. After 72 d=
ays
of follow-up, through evaluations and nursing interventions, considering
aspects of the lesion, there was an increase in granulation tissue and almo=
st
complete healing. Conclusion: nursing work through instrumental
debridement combined with the use of special coverings proved to be incisiv=
e and
decisive for the healing process. &nbs=
p;
Keywords: Pressure Ulcer. Debridement. Nurses. Primary Health Care
RESUMO
Objetivo: descrever a experiência exitosa=
do
tratamento de uma lesão por pressão utilizando técnica=
de desbridamento
instrumental conservador pela enfermeira da Atenção
Primária à Saúde associado ao tratamento com coberturas
especiais. Metodologia: trata-=
se de
uma pesquisa descritiva, exploratória, qualitativa, do tipo estudo de
caso de um paciente com ferida complexa. Realizado na USF Alto de Coutos 2,=
do
Distrito Sanitário do Subúrbio Ferroviário no
município de Salvador, Bahia. Os dados coletados por meio de
observação, entrevista e análise de prontuário =
ao
longo do tratamento. Foram respeitados os aspectos éticos do Conselho
Nacional de Saúde e a pesquisa aprovada pelo comitê de
Ética da Universidade Federal da Bahia. Resultados: A paciente apresentou lesão por pressão em região sacra=
l,
coberta por necrose de coagulação. Foi realizado desbridamento
instrumental conservador do tecido necrótico, sem sangramentos ou ou=
tras
intercorrências, associado ao tratamento com coberturas especiais.
Palavras-chave: Lesão por Pressão. Desbridamento.
Enfermeira. Atenção Primária à Saúde
INTRODUCTION
Pressure Injuries (PL)
are an important problem for the health sector, considering the high
prevalence, including in Primary Health Care (PHC), which is the locus of f=
irst
access for the user, especially in the COVID-19 pandemic. PLs generate great
impacts for the health sector due to their morbidity and mortality, which is
why prophylactic measures are essential to prevent the disease, as well as
knowing the proper management for the treatment of already installed injuri=
es
is extremely important.
Pressure injuries res=
ult
from prolonged soft tissue compression between a bony prominence and an
external surface, which generates ischemia and consequent necrosis of the &=
aacute;rea(1).
Knowledge about the factors that generate PL, its prevention, as well as the
best treatment approaches for this injury is necessary.
It is noteworthy that the developme=
nt of
ulcers has multifactorial causes, the result of a complex process. The
intensity and duration of pressure converge to the collapse of capillaries =
and
consequent interruption of the flow of blood and nutrients, leading to local
ischemia, tissue hypoxia, tissue acidosis, edema and tissue necrosis(2=
).
In addition to pressure, extrinsic factors also constitute: friction, shear,
humidity, as well as the type and time of surgery, anesthesia, surgical
positions and positioning. Added to these are the intrinsic factors that
contribute to the appearance of these ulcers, such as: age, body weight,
nutritional status, level of consciousness, chronic diseases such as diabet=
es
mellitus, vasculopathies, neuropathies, hypertension and anemia(3).
All these factors, whether intrinsic or extrinsic, make rehabilitation
difficult, which increases the risk of developing PL.
According to the
literature, PL prevalence data vary worldwide. Studies carried out in sever=
al
countries, with different methodologies, show a prevalence of 2.9% to 8.34%=
in
Spain, 14.8% in England, 19.1% in the United States, and 23% in Brazil, with
regard to home care(4). These data increase when the reference is
the hospital environment: 15% to 25% in the United States, and 10% to 55% in
Brazil(5).
Despite their high
prevalence, most PL are potentially preventable, considering that there are
several prevention measures, some of them of low complexity and high
effectiveness, such as skin inspection and periodic change of position; the=
use
of pads under bony prominences; the application of scales that determine the
risk of developing PL and standardize behavior from there. In addition to
nursing care, special high-tech coverages are available, which promote
microclimate control and reduce pressure on application sites(2)=
. &=
nbsp;
The costs for the treatment of pati=
ents
with PL are extremely high in Brazil and worldwide.
A study carried out in
Switzerland revealed that the estimated cost of pressure ulcer treatment is
equivalent to US$ 2,000 to US$ 6,000 per patient with a healed lesion, with=
an
average time of 14 weeks(6). In Brazil, a study carried out in M=
inas
Gerais revealed that these costs are around US$ 12,000 per patient with a
healed lesion, with an average time of 20 weeks(7). This data
reveals that in developing countries, the cost for the total healing of an =
PL
is higher and takes longer, which may be related to difficulties in treatme=
nt,
which may be related to the limitation of adequate coverage in health servi=
ces,
many of them costly, in addition to difficulties in the debridement of inju=
ries
by professionals.
As it is a frequent
complication in critically ill patients, PL has a great impact on recovery =
and
quality of life, making it essential to adopt preventive measures, as well =
as
interventions that will favor the cure of these patients. Considering that =
PHC
nurses are healthcare professionals who directly assist patients and play an
important role in the treatment process, including through the assessment a=
nd
debridement of injuries, as well as the prescription of special coverage
Considering the relev=
ance
of the nursing role in the prevention and treatment of pressure injuries, t=
he
following objective emerged: to describe the successful experience of treat=
ing
a pressure injury using a conservative instrumental debridement technique by
the PHC nurse associated with treatment with special dressings.
METHODOLOGY
This is a descriptive, exploratory,
qualitative research, of the case study type, carried out in the city of
Salvador, Bahia(10).
&nb=
sp; The
study setting was the Family Health Unit (USF) Alto de Coutos 2, in the
Sanitary District of Subúrbio Ferroviário (DSSF), from 10/03/=
2021
to 22/04/2021. As inclusion criteria, the following were considered: patien=
ts
with complex lesions, aged over 18 years, who made their participation offi=
cial
by signing the Informed Consent Form (FICF). As exclusion criteria: consecu=
tive
absences, by the patient, without justification, on the days scheduled for =
the
dressing procedure and non-compliance with the guidelines proposed by the U=
SF
nurse. One patient with a complex wound was selected in order to report all
team activities and clinical evolution. Data collection took place through
observation, interviews (nursing history) and medical record analysis, in
addition to other data collection techniques such as: interview with the
accompanying family member and physical examination of the patient. The pat=
ient
in question, due to a neurological deficit, had the consent form filled out=
by
her husband.
The research complies with Resolution
nº 466/2012, of the National Health Council of the Ministry of Health.=
The
research protocol was approved by the Ethics Committee of the Federal
University of Bahia under nº 453.482/2013.
RESULTS
M.J.P.F.S., 62 years old, attended the=
USF
Alto de Coutos II for the first time on 03/10/2021, in the company of her
husband. At the time, she presented neurological disorders, being disorient=
ed
in time, space and quite agitated. He brought with him a discharge report f=
rom
the Emergency Care Unit (UPA) with the following information: admission:
02/12/2021; high: 02/22/2021; diagnostic suspicion: presenting altered leve=
l of
consciousness secondary to stroke (brain CT without alterations); A/E seizu=
re
(resolved); A/E fever (ITU? Pneumonia? Treated).
Upon admission (12/02/2021), her husba=
nd
reports that, upon arriving from work, at 3:00 pm, he found the patient lyi=
ng
on the ground, "hitting" on the floor, having a convulsive crisis,
and being brought to the unit (UPA). She reports that the patient lost
consciousness, becoming sleepy, without recognizing her husband. The same
reports that the last time he saw the patient well was at 7:30 am. She repo=
rts
that on Tuesday, three days prior to admission to the UPA, she had vomiting
episodes during the day and difficulty in urinating. He also reports that he
has already had several convulsive crises. Does not follow up. Denies ische=
mic
history. Patient with Systemic Arterial Hypertension (SAH), using losartan.
Husband denies that he currently has gastrointestinal and respiratory
complications.
Regarding the physical examination on
admission: general: REG, LOT, eupneic, acyanotic, anicteric and afebrile; v=
ital
data: BP: 115x81 mmHg; HR: 138 bpm; FR: 17 irpm; SpO2: 95%; AR: MVBD without
RA; ACV: BRNF in 2T without murmurs; ABD: globose, RHA+; no masses or VMG, =
no
signs of peritoneal irritation; EXT: poorly perfused, edema, redness and he=
at
in MIE; NEURO: GLASGOW 11, PIFR, no focal deficit; MON. CEPHALICAL: scalp
lesion not visualized, however, the stretcher is wet in the head. Evolution
(22/02/2021): hemodynamically stable patient, maintaining improvement in the
level of consciousness, GLASGOW 14. LAB (13/02/2021): Hb: 13; Ht: 38.7; pla=
q:
10730 (S: 83); Ur: 17; Cr: 0.6; TGP: 33; Na: 137; K: 3.8; LAB (22/02/2021):=
Hb:
9.7; Ht: 29.9; leuco: 11,980 (no deviations); plaq: 440,000; Ur: 19; Cr: 0.=
6;
Na: 135; K: 3.9; INR: 1.2; TP: 66%. ECG (12/02/2021): sinus tachycardia. TR
Covid-19 02/14/2021): negative.
The husband states that the patient
remained confined to bed in the same position throughout the hospital stay =
(10
days).
Upon examination, he presented a press=
ure
lesion (PPL) in the sacral region, covered by poorly adhered coagulation
necrosis, especially on the edges, which facilitated debridement (Figure 1)=
. It
presented borders with pale pink granulation and hyperchromic perilesion,
without phlogistic signs.
Figure 1
- First assessment, recorded before debridement. Salvador, Bahia, March 10,
2021.
Source: Own
authorship
The
patient had to be held on the stretcher while the dressing was being applied
due to agitation. In this first moment, conservative instrumental debrideme=
nt
of the necrotic tissue was performed, without bleeding or other complicatio=
ns
(Figure 2). After removing the devitalized tissue, a cavity in the upper
portion of the right buttock was already evidenced.
Figure 2 - Recorded right after conservative
instrumental debridement. Salvador, Bahia, March 10, 2021.
![](3D"1095EVOLUTIONOFPRESSUREtraduzidoHTMLEN_arquivos/image004.gif")
Source:
As primary coverage, a hydrogel with
alginate associated with gauze impregnated with PHMB was used, and the gauze
was introduced as much as possible in order to fill the entire cavity space.
Prescribed daily change. The patient left the unit walking without assistan=
ce.
On 03/11/2021, the subsequent dressing
change was performed by the nursing technician, under the supervision of the
nurse, as prescribed (Figure 3). The observation made was that the patient =
had
removed the covering the night before and the husband covered it with a cle=
an
cloth. This situation occurred other times along the way, but it was observ=
ed
that there was no interference in the evolution of the healing process.
Figure 3
– Second exchange. Salvador, Bahia, March 11, 2021.
![](3D"1095EVOLUTIONOFPRESSUREtraduzidoHTMLEN_arquivos/image006.gif")
Source:
Own
authorship
As part of the unit's routine, the
assessment by the nurse in the dressing room takes place once a week and is
only requested outside the routine in case of need. That's what happened in=
the
exchange on 03/12/2021. The husband reported fever that was not thermometer=
ed
and complained of local pain. Upon evaluation of the lesion, he had poorly
adhered slough and pale pink granulation, in addition to maximum purulent
exudate and a foul odor. It had viable edges. Tax.: 36.9°C. Medical
evaluation was requested, after which antibiotic therapy was prescribed.
On 03/15/2021, after the weekend, the
patient returned with improvement in systemic symptoms and also in the
appearance of the lesion. The granulation was already brighter, however, wi=
th
the presence of thinly adhered sludge (Figure 4). On that occasion, the hus=
band
suggested the possibility of spacing out the exchange interval, as he lived=
far
away and came to the unit on foot. As the lesion was already showing good
evolution, replacement was prescribed every 2 days.
Figure 4
– Third exchange. Salvador, Bahia, March 15, 2021.
![](3D"1095EVOLUTIONOFPRESSUREtraduzidoHTMLEN_arquivos/image008.gif")
Source: Own
authorship
=
Due to the change of routine in health
units caused by the Covid-19 pandemic, the next assessment by the nurse, wh=
ich
would be on 03/19/2021, took place on 03/24/2021. The lesion already had
evident contraction of the edges; the bed, which previously had a very
irregular surface, was already flatter, with the exception of the cavity in=
the
upper portion of the right buttocks, which still had slightly adhered slough
(Figure 6). Again, conservative instrumental debridement of the devitalized
tissue in the cavity was performed.
Figure
5
– Seventh exchange. Salvador, Bahia, March 24, 2021.
![](3D"1095EVOLUTIONOFPRESSUREtraduzidoHTMLEN_arquivos/image010.gif")
Source: <=
/b>Own
authorship
F=
igure
6– Seventh exchan=
ge,
angle that makes it possible to visualize the cavity. Salvador, Bahia, March
24, 2021
![](3D"1095EVOLUTIONOFPRESSUREtraduzidoHTMLEN_arquivos/image012.gif")
Source: Own
authorship
<= o:p>
<= o:p>
<= o:p>
F=
igure
7– Injury follow-=
up.
Salvador, Bahia, May 21, 2021
![](3D"1095EVOLUTIONOFPRESSUREtraduzidoHTMLEN_arquivos/image014.gif")
Source:
It
is noteworthy that on that date, the patient reports that she will go to the
interior, in the family's house. In this last consultation, the nurse provi=
des
guidance on the use of gauze with petrolatum, with changes every 48 hours, =
and
prepares a reference form and delivers it to the patient.
DISCUSSION
Pressure Injury in Primary Health
Care
According to
epidemiological data related to LP in Brazil, 19.1% to 39.4% of hospitalized
patients have this type of injury. Data regarding the occurrence of LP at h=
ome
are restricted, and PHC is the first service accessed by patients, responsi=
ble
for referring patients, when necessary, for specialized care(11)=
. In
the meantime, efficient curative and preventive care practices need to be
implemented at all levels of care, as well as in the PHC under the care of =
the
USF, where there is the establishment of guidelines aimed at the practice of
prevention, emphasizing health promotion actions.
Chronic wounds treate=
d in
PHC are mentioned by nurses as recurrent injuries, characterized as a compl=
ex
injury when associated with systemic pathologies that impair the healing
process, such as hypertension, chronic venous disease, arterial disease and
peripheral neuropathy, physical trauma, infections cutaneous lesions and tu=
mors(12-13),
as was the case of the reported patient, with SAH, using Losartan.
Highlighting SAH as a
predisposing factor to PL, explained by the increase in peripheral vascular
resistance, associated with the use of antihypertensive drugs, which reduce
blood flow and tissue perfusion, facilitating the onset of PL(14). In addit=
ion
to these, diseases such as Alzheimer's and cerebrovascular accident sequelae
increase the risks of developing LP because they result in reduced physical
mobility, considered as a condition of major importance in the development =
of LP,
as it affects the ability to effectively relieve pressure (14-15).
Skills of nursing
professionals in the prevention, assessment and treatment of skin lesions
through special coverage
Healing is a
physiological process of repairing damaged tissues and requires the health
professional to have basic knowledge about the physiology of the skin, fact=
ors
that interfere with healing, and systematic assessments, with prescriptions=
for
frequency and type of coverage needed to reconstitute the injured tissue
The literature points=
out
that the treatment and measures to prevent wounds are the responsibility of
nurses, and they must carry out daily assessment of the client's clinical
status as a way of prevention, and in cases of presence of PL, perform the
wound assessment, determining factor for proper therapy, in addition to
instructing the nursing staff and supervising them in the execution of
dressings(18).
Although in terms of
nursing care to prevent injuries, changes in position at scheduled times for
bedridden patients are essential, redistributing the pressure concentrated
under the bony prominences and minimizing shear areas(19). It was
found that the patient remained contained in bed in the same position
throughout the hospital stay (SIC) in the Emergency Care Unit, evolving to =
LP
in the sacral region, covered by wet coagulation necrosis. This is reckless
data, considering the harmful potential of PL, which is an avoidable proble=
m in
most cases, which prolongs hospitalizations, increases hospital costs,
increases the risk of sepsis and increases morbidity(20).
In that study, the
association of two special dressings was used: mead with alginate and gauze
impregnated with PHMB. It is noteworthy that mead with alginate has the
function of promoting the hydration of the lesion, absorption of the exudate
and autolytic debridement. Antimicrobial gauze is a 100% cotton woven gauze
dressing impregnated with Polyhexamethylene Biguanide (PHMB), an antimicrob=
ial
agent with a broad spectrum of action against microorganisms such as bacter=
ia,
fungi and yeasts, indicated for the treatment of colonized, infected or with
high risk of infection, considering that its high-quality weave offers grea=
ter
protection against infection, facilitates handling and reduces the risk of
fraying or adhering to the wound bed on removal.
Studies reinforce that PHMB is
structurally similar to natural antimicrobial peptides that are produced by
many living beings and has a broad spectrum of action against bacteria, vir=
uses
and fungi(21). Corroborating these findings, studies show that t=
he
use of gauze impregnated with PHMB is considered effective in the treatment=
of
complex wounds with regard to pressure injuries (22).
It is up to the nurse,
after evaluating and stratifying the risk, to be concerned with developing
effective prevention protocols and strategies, promoting training and
educational actions, standardizing care and its applicability involving the
team in this process so that everyone follows the same assessment standards=
, treatment
and prevention of injuries. Simple measures such as effective decubitus cha=
nge
and acquisition of appropriate materials that provide relief in pressure zo=
nes,
promote patient comfort, reduce the LP rate, reduce unnecessary expenses, in
addition to avoiding physical and psychological suffering that these injuri=
es
can bring to the patient.
Cofen Resolution No.
160/93, in its Article 16, makes it a duty and responsibility of the nursing
professional to ensure the client's assistance free from damage resulting f=
rom
imprudence, negligence or malpractice(23). Actions developed to
raise awareness and engage all professionals involved in patient care about=
the
importance of prevention, from admission to discharge, are relevant to ensu=
re
better results in the pursuit of quality care provided, providing safe,
humanized and harm-free care . The occurrence of LP is considered an indica=
tor
of quality in nursing care. As a result, the Ministry of Health (MS) publis=
hed
on April 1, 2013, Ordinance no. 529, which instituted the National Patient
Safety Program (PNSP), which has the prevention of pressure injuries as one=
of
its work axes(24).
In a study with inten=
sive
care nursing professionals from an educational institution in the State of
Ceará, most recognize the necessary nursing care to prevent PL such =
as
changing position, in addition to care with bone prominences, application of
dressings with hydrocolloid, AGE, film , collagenase, patient hydration,
friction and shear reduction(18). However, in practice, they rep=
ort
difficulties with the surveillance and prevention of PL, essentially with
regard to changing the position every two hours and identifying the risk of=
PL.
In the recognition of=
patients
at risk of developing PL, in addition to changes in position, it is recomme=
nded
to improve the professionals' ability to use a measurement instrument, such=
as
the Norton, Braden, Gosnell and Waterlow scales, which present adequate
validity indices. predictive, sensitivity and specificity(25).
In view of the provis=
ion
of quality care promoted by nurses in the prevention of PL, two Australian
studies find ambiguity in answers regarding the difficulties encountered by
these professionals, in knowing how to organize priorities and deal with
challenges at the organizational level of the institution, such as the
dimensioning of the team for PL surveillance and prevention, reverberating =
in
task overload, higher occurrence of adverse events and deficits in the qual=
ity
of care (26-27).
In this context, the
nursing professional fills an important gap in the treatment of wounds and
these should be recognized as a preponderant figure of great relevance in t=
he
care of patients or those at risk of developing wounds. This professional
maintains prolonged contact with the client, assesses the injury, plans
actions, coordinates care, monitors the evolution and not only supervises a=
nd
performs the dressings prescribed by the physician, performing highly relev=
ant
work.
For a correct diagnos=
is
of the type of injury and success in prescribing the most suitable type of
treatment, it depends more on the competence and knowledge of the professio=
nals
involved, on their ability to properly assess and select techniques and res=
ources,
than on the availability of resources and technologies sophisticated. Nurses
are essential in the assessment, classification, treatment and monitoring of
skin lesions and must base their care practice on new knowledge, ensuring t=
he
implementation of prevention measures and the correct use of the covers
provided by the institution, considering the peculiarities of the lesion and
the patient for adequate therapy and faster improvement of these lesions
Due to the complexity=
of
the clinical management of the PLs described above, it is up to the nurse to
know about the entire process that involves the treatment of the patient an=
d to
develop the same standards of assessment, treatment and prevention for the
entire team involved in the care.
That said, the mo=
nitoring
and evaluation performed by the nurse in the dressing room once a week was
evidenced and it is only requested outside the routine in case of need. The
authors(28,29) point out the importance of patients being monito=
red
and continuously evaluated about their general state of health, undergoing
consultations whenever necessary, as was done.
Some authors envision=
the
nurse's autonomy in ordering microbiological exams as parameters in determi=
ning
the most adequate coverage, as these exams signal, in addition to the types=
of
bacteria present in the wound bed, the number of colonies and this is direc=
tly
linked to the conditions of infection or no, therefore, guiding the need to=
use
antimicrobial coverage(29). It is up to the professional nurse,
according to Cofen Resolution No. 04/2016, to carry out sample collection f=
or
microbiological tests upon authorization and request through a medical requ=
est,
being a challenge for nurses nationwide to identify and diagnose a wound
infection only with clinical evaluation , without the possibility of using
non-invasive microbiological tests in practice(30).
It should be noted th=
at
investing in continuing education with nurses who actively work in the
prevention and assessment of complex wounds can allow the exchange of
experiences from the case discussions of patients assisted in daily life, in
order to address the weaknesses in professional practice or even in insecur=
ity
about the products available on the market and their particularities(9=
).
Legal
competence of nurses to perform debridement
In the presence of
necrotic tissue in the wound bed, which interferes with tissue repair, as w=
ell
as any foreign body, there is a need to remove the necrosis, reducing the
bacterial load, toxins and other substances that inhibit healing(31).
Its benefits and favoring the growth of granulation tissue and adequate
revitalization are supported by national and international publications
As observed in the
patient, the presence of necrotic tissue, it was decided to perform
conservative instrumental debridement of necrotic tissue, without bleeding =
or
other complications. There was a cavitary wound in the upper portion of the
right buttock, using a hydrogel with alginate associated with gauze impregn=
ated
with PHMB. After the removal of the devitalized tissue, the patient's return
for further evaluations showed evolution of the general appearance of the
lesion, with exudate control and formation of granulation tissue.
Conservative instrume=
ntal
debridement is a conservative approach, which can be performed at the bedsi=
de
or in an outpatient setting, to remove necrotic tissue, without causing pai=
n or
bleeding, using techniques known as: Cover, Slice and Square(34).
This procedure requires technical-scientific competence from the nurse, as =
it
uses sharp instruments and should only be performed when there is adequate
perfusion around the wound(35).
It is essential to en=
sure
that the entire range of professional practice is always in accordance with=
the
legislation of the professional association, regarding the possibilities of
treatment, debridement and prescription of coverage, as clarified in the
following documents: Opinion COREN-SP 002/2015 - CT (Prescription of dressi=
ngs
for wound treatment by a Nurse)(36); Opinion COREN-SP CAT No.
013/2009 – (Performance of debridement by the nurse)(37) a=
nd
Opinion No. 04 /2016 CTAS COFEN (Manifestation of procedures in the nursing
area)(30). Professional autonomy cannot be dissociated from the
responsibilities assigned to decision-making, it being necessary that nurse=
s in
their practice honestly recognize their limits of knowledge, skills and
personal aptitudes, improving treatments, such as the practice of debrideme=
nt
and thus contributing to the reduction of delays in the wound healing proce=
ss.
The authors(34)<= /sup>, in a study carried out with nurses from the Family Health Strategy (FHS) in= a municipality in southern Brazil, found that although most nurses recognize debridement techniques and contraindications, they manifest insecurity in c= hoosing the best method to use, they do not feel able and safe to perform it, a reflection of the fragility of instrumentation, as they report that knowled= ge was acquired only at graduation and the distance from this daily practice.<= o:p>
Based on the above, a=
lthough
nurses have legal support to carry out conservative instrumental debridemen=
t,
as long as they feel fit, there is a need to empower themselves with this
knowledge, and the search for specialization and training is essential. It
emphasizes the importance of nurses introducing instrumental debridement in
their care, in order to minimize the number and period of hospital admissio=
ns,
as well as infections and costs with wound treatment, while ensuring the
success of the healing process in consonance with the specificities of the
population(34). It is noteworthy that these in-service training
aimed at performing debridement was promoted by the nurse of technical
reference in dressings of the DSSF, in order to train nurses in the units w=
ith
the aim of providing comprehensive, holistic, humanized care, minimizing
complications and pilgrimages of the patient in search of professionals who
perform this procedure.
Humanized
care
In addition to the
treatment of the complex wound, the preparation of the wound bed, prescript=
ion
of adequate coverage, it is necessary to understand determining factors that
involve the patient with the wound, their particularities, comorbidities and
thus, welcoming, listening and giving positive responses to both individual
needs. as collective to the people cared for(29). For this, it is
necessary that the professionals involved are available to listen and value=
the
desires, feelings, behaviors and needs of the patient and family, so that,
together, they can plan care actions, in order to go beyond technical
competence and mastery biological.
Thus, it is noted that
the injury is installed in the physical part, but affects the psychological=
and
emotional side, as it affects the individual's life and way of being and be=
ing
in the world. In this aspect, it is worth emphasizing the importance of
clarifying to patients, providing guidance on how the lesion evolves, in or=
der
to provide support in living with it. It is essential that patients with
chronic injuries receive care marked in humanized care, qualified and detai=
led
listening, have emotional and psychological support throughout the therapeu=
tic
process. Understanding individuality in coping with the adversities of life
and, in this case, the wound, will bring fundamental resources for nurses to
offer holistic care, increasingly humanized (38).
In this context, it w=
as
possible to observe in the reported case the guarantee of the humanization =
of
care, considered relevant in the act of caring. Considering the evolution in
the wound healing process and the daily mobility difficulties to change
dressings with the patient's husband's request for spacing between returns =
to
the USF, the nurse changed the prescription to every 2 days.
From this perspective,
for humanized and individualized care, it is the responsibility of nursing =
to
provide immediate care and systematize care, surveying the diagnosis, plann=
ing
interventions and evaluating the care provided. In the case of patients with
chronic wounds, nursing diagnoses must thus highlight the patient's other
needs, in addition to the physical injury, in order to understand the
particularities of each context of life and thus plan the interventions to =
be
developed. It is up to the team, when caring for people with wounds, to bui=
ld a
therapeutic bond by evaluating the individual and the potential risks. Thus=
, it
is possible to provide guidance on the necessary procedures and care, making
dressings and following the principles of healing and skin health recovery =
in a
systematic and evidence-based way(39).
Complex wounds compro=
mise
the quality of life of their patients, bringing several factors that affect
their social life, such as low self-esteem and changes in body image,
depression, anxiety, pain and mobility difficulties(40).
Corroborating the study carried out by Aguiar(41), with eight
elderly people in a Physiotherapy clinic in the interior of Bahia, patients
with venous ulcers experience situations of shame, embarrassment, prejudice=
and
limitations resulting from the wounds.
The nurse also has an essential rol=
e in
sensitizing the patient to follow their guidelines, since in the nursing
consultation the professional must prescribe and guide the treatment, in
addition to clarifying all doubts and reinforcing the importance of continu=
ity
of care, since, it is known that a well-informed patient has better adheren=
ce
to treatment(42).
FINAL
CONSIDERATIONS
This study made it
possible to demonstrate, from the clinical case report on nursing care in
patients with pressure injuries, how relevant the possibility of treating t=
he
injury with effective methods, such as instrumental debridement of conserva=
tive
necrotic tissue and the use of special dressings for optimize the formation=
of
granulation tissue and the LP healing process. In addition to reinforcing t=
he
importance of implementing prevention measures, such as changing positions =
and
risk assessment through the use of scales with predictive validity and
humanized care with emotional and psychological support during the therapeu=
tic
process. This corroborates the relevant work of the nursing team for the
treatment of LP based on the best scientific evidence.
Although this is a to=
pic
discussed in scientific publications, epidemiological data point to a high
prevalence and incidence of pressure injury, requiring nurses to know about
essential strategies for the maintenance and integrity of the skin, which i=
s a
challenge for this professional who must propose strategies and develop
adequate protection, prevention and treatment actions.
REFERENCES
1. Li D, Mathews C. Automated
measurement of pressure injury through image processing. J Clin Nurs. 2017;=
26(21-22):3564-3575.
doi: 10.1111/jocn.13726. Epub 2017 Apr 3. PMID: 28071843.
2. Jackson D, Durrant L, Bishop E,
Walthall H, Betteridge R, Gardner S, et al. Pain associated with pressure
injury: A qualitative study of community-based, home-dwelling individuals. J
Adv Nurs. 2017; 73(12):3061-3069. doi: 10.1111/jan.13370 3. Corbett LQ, Funk M, Fortunato =
G,
OʼSullivan DM. Pressure Injury in a Community Population: A Descriptive
Study. J Wound Ostomy Continence Nurs. 2017; 44(3):221-227. doi:
10.1097/WON.0000000000000320. PMID: 28328647. 4. Soares CF, Heidemann ITSB. Pro=
moção
da saúde e prevenção da lesão por pressã=
o:
expectativas do enfermeiro da atenção primária. Texto
contexto - enferm. [Internet]. 2018 [cited 2021 Apr 20]; 27(=
2):
e1630016. Available from: http://www.scielo.br/scielo.php?script=3Dsci_artt=
ext&pid=3DS0104-07072018000200301&lng=3Den.
5. Mendonça ASGB, Rocha AC dos S, Fernandes TG. Perfil
epidemiológico e clínico de pacientes internados com les&atil=
de;o
por pressão em hospital de referência no Amazonas. Rev Epidemi=
ol e
Control Infecção [Internet]. 2018; 8(3):253–60. Availab=
le from:
https://online.unisc.br/seer/index.php/epidemiologia/article/view/11857
6. Meier C, Boes S, Gemperli A, Gmünder HP, Koligi K, Metzger S, et=
al.
Treatment and cost of pressure injury stage III or IV in four patients with
spinal cord injury: the Basel Decubitus Concept. Spinal Cord Ser Cases
[Internet]. 2019; 5(1):30. Available from: http://www.nature.com/articles/s=
41394-019-0173-0
7. Vieccelli Donoso MT, Barbosa SAS, Simino GPR, Couto BRGM, Ercole FF,
Barbosa JAG. Análise de custos do tratamento de lesão por
pressão em pacientes internados. Rev Enferm do Centro-Oeste Min
[Internet]. 2019 [cited 2021 abr 26]; 9. Available from: http://seer.ufsj.e=
du.br/index.php/recom/article/view/3446
8. Ricci JA, Bayer LR, Orgill DP. Evidence-Based Medicine. Plast Reconstr
Surg [Internet]. 2017; 139(1):275e-286e. Doi: 10.1097/PRS.0000000000002850<=
/span>
9. Cauduro FP, Schneider SMB, Men=
egon
DB, Duarte ERM, Paz PO, Kaiser DA. Atuação dos enfermeiros no
cuidado das lesões de pele. Revista de Enfermagem UFPE, 2018; 12(10)=
: 2628-2634.
10. Yin RK. Estudo de caso:
planejamento e métodos. 3 ed., Porto Alegre: Bookman; 2005.
11. Stuque AG, Sasaki VDM, Teles A=
AS,
Santana ME, Rabeh SAN, Sonobe HM. Protocolo para prevenção de
úlcera por pressão. [Internet]. Rev Rene. 2017 [Cited 2019 Apr
19]; 18(2):272-282. http://dx.doi. org/10.15253/2175-6783.2017000200018
12. Garcia AB, Müller PV, Paz=
PO,
Duarte ERM, Kaiser DE. Percepção do usuário no autocui=
dado
de úlcera em membros inferiores. [Internet]. Rev Gaúcha Enfer=
m.
2018.[Cited 2019 Apr 19]; 39:e20170095. Available from: http://dx.doi.org/10.1590/1983-1447.2018.2017-0095<=
u>
13. Ribeiro GSC, Cavalcante TB, Sa=
ntos
KCB, Feitosa AHC, Silva BRS, Santos GL. Pacientes internados com feridas
crônicas: um enfoque na qualidade de vida. Rev Enferm Foco [Internet].
2019 [Cited 2019 Oct 02]: 10(2):70-75. Available from: http://revista.cofen=
.gov.br/index.php/enfermagem/article/view/1740/524
14. Coqueiro JM, Brito RS.
Múltiplos fatores de riscos e estratégias preventivas das
úlceras por pressão: revisão sistemática. Rev de
enfermagem UFPE On line [Internet]. 2013 [acesso em 22 nov 2018]; 7(10): 62=
15-
22. Disponível em: https://periodicos.ufpe.br/revistas/revistaenferm=
agem/
article/download/12259/14893.
15. Guerra MJC, Alvim JP, Salles L=
O, Albergaria
RMR, Teixeira JCD, Queiroz AT. Abordagem e tratamento de úlcera de
pressão infectada em idosa sob cuidado domiciliar: da
atenção primária à especializada. Revista de
Saúde. 2021; 12 (1): 30-34
16. <=
![endif]>Medeiros AD, Oliveira GDM, Vasconcelos SCM, Silva JB, Almeida PF, Alv=
es
ESRC. Percepção do enfermeiro sobre a relevância na
avaliação e registro das injúrias cutâneas no
prontuário do paciente. Brazilian J Heal Rev [Internet]. 2020; 3(5):=
11603–14.
Available from: https://www.brazilianjournals.com/index.php/BJHR/article/vi=
ew/16053/13144
17. <=
![endif]>Oliveira LSB, Costa ECL, Matias JG, Amorim LLB. Os efeitos da
capacitação da equipe de enfermagem sobre avaliaç&atil=
de;o
e cuidado de pacientes com feridas. Brazilian J Dev [Internet]. 2020; 6(5):=
29707–25.
Available from: http://www.brazilianjournals.com/index.php/BRJD/article/vie=
w/10404/8797
18. <=
![endif]>Martins NBM, Brandão MGSA, Silva LA, Mendes AMV, Caetano
JÁ, Araújo TM de et al. Percepção de enfermeiro=
s de
terapia intensiva sobre prevenção de lesão por
pressão. Rev Atenção à Saúde [Internet].
2020 Mar 24;18(63). Available from: http://seer.uscs.edu.br/index.php/revis=
ta_ciencias_saude/article/view/6270
19. Costa CR, Costa LM,
Boução DMN. =
Escala
de Braden: a importânci=
a da
avaliação do risco de úlcera de pressão em
pacientes em uma unidade de terapia intensiva. Rev Recien. 2016; 17 (6):36-44. http://dx.doi.org/10.24276/rrecien2358-3088.2016.6.17.36-44
20. Terra MR, Silva RS, Pereira MG=
N,
Mitrovini C. Enterococcus spp e Staphylococcus aureus em lesão por
pressão. BJSCR, 2017; 18(2):141-148.
21. <=
![endif]>Marquardt C, Koppes P, Krohs U, Mares A, Paglinawan R, Höfer D, =
et
al. Vakuumtherapie mit PHMB Gaze zur Behandlung postoperativer subkutaner
Bauchdeckeninfektionen. coloproctology [Internet]. 2014 [cited 2021 abr 26]=
; 36(5):364–9.
Available from: http://link.springer.com/10.1007/s00053-014-0478-1
22. Alves ILM, Santana LA, Neves R=
S, Guadagnin
RV. A efetividade da Polihexanida (PHMB) na cicatrização de
lesão por pressão: um estudo preliminar. Revista feridas, 201=
8;
06(30):1008-1014.
23. Conselho Federal de Enfermagem.
Resolução Cofen 160/93. In: Documentos Básicos do Cofe=
n. 4
ed. Rio de Janeiro, Cofen; 1996.
24. Brasil. Portaria nº 529, =
de
1º de abril de 2013. Institui o Programa Nacional de Segurança do Paciente (PNSP).
Diário Oficial da União, 2013.
25. Rocha SCG, Oselame DG, Mello MGS, Neves EB. Comparação das
escalas de avaliação de risco de lesão por
pressão. Rev Bras Pesq
Saúde. 2016; 18(4):
26. Latimer S, Gillespie BM, Chabo=
yer
W. Preditor of pressure injury
prevention strategies in at-risk medical patients: an Australian multi-centre study.<=
span
style=3D'mso-spacerun:yes'> Collegian. 2017; 24
(3): 155-163. https://doi.org/10.1016/j.colegn.2015.11.00522.
27. Barakat-Johnson M, Lai =
M,
Wa n d T, =
White
K. A qualitative study of the
thoughts and experiences of hospital nurses providing pressure injury
prevention and management.
Collegian. 2018;
558(2): 1-8. https://doi.o=
rg/10.1016/j.colegn.2018.04.005
28. Favreto FJL, Betiolli SE, Silva
FB, Campa A. O papel do enfermeiro na prevenção,
avaliação e tratamento das lesões por pressão. =
Rev.
Gestão e Saúde, 2017;17(2):37-47.
29. Lúcio FD, Polleti NAA. =
Prática
diária do enfermeiro atuante no tratamento de feridas. Cuid Enferm. =
2019;
13(2): 206-208.
30. Conselho Federal de Enfermagem.
Parecer nº 04/2016/CTAS/COFEN. Ementa: Manifestação dos
procedimentos da área de enfermagem). [Internet]. [citado em 22 jun.
2019]. Disponível em: http://www.cofen.gov.br/parecer-no-042016ctasc=
ofen_45837.html
31. Brem H, Kirsner RS, Falanga V.
Protocol for the successful treatment of venous ulcers. The American Journa=
l of
Surgery, 2004; 188:1-8.
32. National Pressure Ulcer Adviso=
ry
Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Inju=
ry
Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guid=
e.
Emily Haesler (Ed.). Cambridge Media: Perth, Australia; 2014.
33. <=
![endif]>Strohal R, Dissemond J, Jordan O’Brien J, Piaggesi A, Rimdeika =
R,
Young T, et al. EWMA Document: Debridement: An updated overview and
clarification of the principle role of debridement. J Wound Care [Internet].
2013 Feb;22(Sup1):S1–49. Available from: http://www.magonlinelibrary.=
com/doi/10.12968/jowc.2013.22.Sup1.S1
34. <=
![endif]>Girondi JBR, Soldera D, Evaristo SM, Orlandi Honório Locks M,
Amante LN, De Souza Vieira A. Desbridamento de feridas em idosos na
atenção primária em saúde. Enferm em Foco
[Internet]. 2020 May 25;10(5). Available from: http://revista.cofen.gov.br/=
index.php/enfermagem/article/view/2669
35. Conselho Federal de Enfermagem.
Resolução 0567/2018, de 29 de janeiro de 2018. Regulamenta a
atuação da equipe de enfermagem no cuidado aos pacientes com
feridas. [Internet]. Brasília: COFEN; 2018. [Cited 2019 Apr 19].
Available from: http://www.cofen.gov.br/wp-content/uploads/2018/02/RESOLU%C3%87%C3%83=
O-567-2018.pdf
36. Conselho Regional de Enfermage=
m de
São Paulo. Parecer COREN-SP 002/2015 – CT. Ementa:
Prescrição de coberturas para tratamento de feridas por Enfer=
meiro.
[Internet]. [citado em 22 jun. 2019]. Disponível em:
https://portal.coren-sp.gov.br/wpcontent/uploads/2015/04/Parecer%20002-
2015%20Prescri%C3%A7%C3%A3o%20coberturas-1.pdf
37. Conselho Regional de Enfermage=
m de
São Paulo. Parecer COREN-SP CAT Nº 013/2009. Assunto:
Realização de desbridamento pelo Enfermeiro. [Internet]. 2009
[citado em 22 jun. 2019]. Disponível em:
https://portal.corensp.gov.br/sites/default/files/parecer_coren_sp_2009_13.=
pdf
38. Leal TS, Oliveira BG de, Bomfim
ES. Percepção de pessoas com a ferida crônica. <=
span
style=3D'font-size:12.0pt;font-family:"Times New Roman",serif;mso-bidi-font=
-weight:
bold'>Rev enferm UFPE on line., 2017; 11(3):1156-62.
39. Frederico GA, Kolchraiber FC, =
Sala
DCP, Rosa AS, Gamba MA. Integralidade no cuidado de enfermagem às
pessoas com úlceras cutâneas. Rev enferm U=
FPE
on line., Recife, 2018; 12(7):1997-2011.
40. Dias TYAF, Costa IKF, Melo MDM, Torres SM da SGS de O, Maia EMC, Torr=
es G
de V. Quality of life assessment of patients with and without venous ulcer.=
Rev
Lat Am Enfermagem [Internet]. 2014; 22(4):576–81. Available from: htt=
p://www.scielo.br/scielo.php?script=3Dsci_arttext&pid=3DS0104-116920140=
00400576&lng=3Den&tlng=3Den
41. <=
![endif]>Aguiar AC de SA, Sadigursky D, Martins LA, Menezes TM de O, Santos AL=
de
S, Reis LA dos. Repercussões sociais vivenciadas pela pessoa idosa c=
om
úlcera venosa. Rev Gaúcha Enferm [Internet]. 2016;37(3).
Available from: http://www.scielo.br/scielo.php?script=3Dsci_arttext&pi=
d=3DS1983-14472016000300417&lng=3Dpt&tlng=3Dpt
42. Dantas DV. Validaç&atil=
de;o
clínica de protocolo de ulceras venosas na alta complexidade. Revista
Gaúcha de Enfermagem, 2016; 37(4):1-9.
Approval=
: 2021-06-08
[1] Secretária Mu=
nicipal
de Saúde de Salvador. Distrito Sanitário do Subúrbio
Ferroviário. Rua da Grécia, n°3 A Ed. Caramuru –
Comércio, Salvador – Bahia, Brasil. Email: lilia.sales@hotmail.com. Orcid:=
https://orcid.org/0000-0002-9319-0557
[2] Técnica de
enfermagem. SMS. Email: ivaldina_braga3@hotmail.com=
.
Orcid: https://orcid.org/0000-0001-7867-0811
[3] Enfermeira. Doutora =
em
Enfermagem e Saúde. Docente da Universidade Estadual de Feira de
Santana. E-mail: nanmatheus@yahoo.com.br. Orcid: https://orcid.org/0000-0001-7501-6187.
[4] Graduanda em Enfermagem. Universidade Estadual de Fei=
ra de
Santana (UEFS). Departamento de Saúde. Feira de Santana-BA, Brasil.
E-mail: fcarolenf@gmail.com. Orcid: http://orcid.org/0000-0003-4464-8389
[5] Enfeimeira SMS. Emai=
l: vanabina@yahoo.com.br.
Orcid: https://orcid.org/0000-0002-9316-1086
[6]=
Enfermeira SMS. Email: renatareis19@gmail.com.
Orcid: https://orcid.org/0000-0002-8121-4451
[7] Enfermeira. Mestre em Enfermagem. Hospital Geral do E=
stado
da Bahia. E-mail: danielafagundes@hotmail.com. Orcid: https://orcid.org/0000-0003-4804-7257
[8] Enfermeira. Especialista em enfermagem Oncológ=
ica;
Mestranda da Universidade Federal da Bahia. Docente do Centro
Universitário Maurício de Nassau. Email: acibelegaspar@gmail.com.
Orcid: https://orcid.org/0000-0001-9477-3757
[9]=
Enfermeira. Doutora em Enfermagem. Docente da Univers=
idade
Federal da Bahia. E-mail: rarriosdavid@gmail.com. Orcid:
https://orcid.org/0000-0003-1316-2394.
[10] Enfermeira. Mestranda pelo Programa de Pós-Gra= duação em Enfermagem e Saúde da Universidade Federal da Bahia. Universidade Federal da Bahia. Escola de Enfermagem. R. Basílio da Gama, 241 - Canela, Salvador – Bahia, Brasil. Email: slnayaraa@gmail.com. Orcid: = https://orcid.org/0000-0001-7911-012X