NURSE=
S '
PERFORMANCE IN PRESSURE INJURIES IN PATIENTS IN THE INTENSIVE CARE UNIT
ATUAÇÃO DO ENFERMEIRO NAS LESÕES POR
PRESSÃO EM PACIENTES DE UNIDADE DE TERAPIA INTENSIVA
Camila Souza Rodrigues
* Cíntia de Carvalho Silva
* Diego Augusto Lopes Oliveira
* Janaína Pereira de Melo Macêdo
* Letícia Mayara da Silva
* Mayra Eloisa da Silva
* Milena Larissa Ferreira da Silva
* Tainara Joana Alves de Souza
ABSTRACT
Objective: Elucidate
the role of nurses in the care of clients affected by pressure injuries in
Intensive Care Unit beds. Methods: Integrative literature review,
carried out through data collection in scientific articles in the LILACS,
BDENF, and MEDLINE databases, in Portuguese, English, and Spanish, between =
the
years 2015 to 2020. Titles, abstracts, and complete articles that responded=
to
the proposed objective were read and classified as summaries of the results=
of
the four selected papers. The search strategy followed the PICOS strategy
according to PRISMA assumptions. Results: Pressure injuries represen=
t a
public health problem due to a large number of people with pressure injurie=
s,
however, everyone involved in the care must be aware of how to properly tre=
at
pressure injuries, in order to prevent them. It is necessary to promote an
adequate, and permanent education for the acquisition of skills about action
planning, starting with the assessment of it, as well as prevention and
treatment. Conclusion: This study concluded that nurses have a
crucial role in the treatment and application of measures to prevent pressu=
re
injuries. Therefore, this review has enabled a greater understanding of the
main actions of nurses in pressure lesions, as well as the procedures to be
adopted during the attendance to the patients with these wounds, always see=
king
the best care and best treatment possible. Keywords: Nursing; Pressu=
re
Injury; Intensive Care Unit.
RESUMO
Objetivo: Elucidar a
atuação do enfermeiro no cuidado ao cliente acometido por
lesões por pressão em leitos de Unidade de Terapia Intensiva.=
Métodos:
Revisão integrativa da literatura, feita através de coletas de
dados em artigos científicos nas bases de dados LILACS, BDENF e MEDL=
INE,
em português, inglês e espanhol, entre os anos de 2015 a 2020.
Realizou-se a leitura dos títulos, resumos e dos artigos completos q=
ue
respondessem ao objetivo proposto e apresentaram-se as sínteses dos
resultados dos quatros artigos selecionados. A estratégia de busca
seguiu a estratégia PICOS conforme pressupostos do PRISMA. Result=
ados:
As lesões por pressão representam um problema de sa&uacut=
e;de
pública em virtude do grande número de pessoas com lesã=
;o
por pressão, entretanto é importante que todos os envolvidos =
no
cuidado tenham conhecimento de como tratar de maneira adequada as les&otild=
e;es
por pressão, a fim de evitá-las. É necessário
promover educação permanente adequada para
aquisição de competências no que diz respeito ao
planejamento de ações, iniciado pela avaliação =
ao
planejamento de ações, como também a
prevenção e o tratamento. Conclusão: Este
trabalho concluiu que o enfermeiro tem papel crucial no tratamento e na
aplicação de medidas de prevenção das les&otild=
e;es
por pressão. Assim, essa revis&atil=
de;o
possibilitou uma maior compreensão das principais açõe=
s do
enfermeiro na lesão por pressão, bem
como dos procedimentos a serem adotados durante
o atendimento aos pacientes com essas feridas, visando sempr=
e o
melhor atendimento e o melhor tratamento possível.
Palavras-chave: Enfermagem; Lesão por Pressão;
Unidade de Terapia Intensiva.
INTRODUCTION
Pressure lesion (PL) is a problem
that is increasingly present in patients who are kept in hospital for a
prolonged period, especially in the Intensive Care Unit (ICU). They are
conceptualized as localized areas of cell necrosis that act on bone promine=
nces
exposed to pressure for a sufficient period to cause tissue ischemia. In the
context of the ICU, due to the restrictions imposed on patients, such as be=
ing
placed in a bed with venous access and often mechanical ventilation associa=
ted
with severe clinical conditions and more complex therapies, patients become
vulnerable to developing it (1, 2).
It is remarkable that public hea=
lth
in general faces huge problems concerning patient safety, there is cultural
influence and available resources. Owing to this reality, Brazil, which is =
part
of the World Alliance for Patient Safety, created by the World Health
Organization (WHO) in 2004, instituted the National Patient Safety Program
(PNSP) by the Ministry of Health, through Ordinance No. 529, of April 1, 20=
13,
intending to quality health care in all health establishments in the nation=
al
territory ( 3, 4).
It is elucidated that one of the
challenges for the health service is the pressure injuries occurrence when =
they
happen, they are considered an indicator of the quality of nursing care
provided to patients. Its emergence can have negative implications for the
patient, such as pain, discomfort, and infections, which can worsen their
health status and even lead the patient to death, as well as having
implications for the institution that is offering the hospitalization, beca=
use
the recovery process becomes slow, there is an increase in infection rates,
consequently, there will be an increase in expenses for the treatment, the
nursing dimensioning becomes more rigorous as more time is needed to provide
care.
It was found that in situations =
of
negligence in health care for patients with pressure injuries, the damage
caused can result in death or permanent sequelae, increasing the cost and
length of hospital stay. However, when the care provided is adequate, the f=
ocus
on the patient's health and recovery is maintained, with a reduction in the
incidence of the disease and a shortening of the treatment and/or
hospitalization time³.
It is believed that, concerning =
the
care provided by the nursing staff to ICU patients at risk of PL, it is
necessary to have a frequency of changes in decubitus in order to reduce
pressure on the body surface and maintain blood circulation. In considerati=
on
of this same physiological perspective, it is relevant to protect the bony
prominences. Another essential practice is nutritional care, malnourished
patients are more susceptible and twice as likely to develop skin lesions as
PL. Be careful with the application of emollients to the skin, because they
replace the barrier function resulting from the loss of natural
lubrication³.
The occurrence records of Pressu=
re
Injury in critically ill patients in Brazil vary between 11% and 88%¹,=
an
incidence above that published in the international literature, which is 4.=
9%
to 25.1% 5. According to the national report of incidents, this high number=
is
related to assistance to health, so between January 2014 and July 2017, were
reported 134 501 incidents; of which, 17.6% are referring to the occurrence=
of
PL, stage III being prevalent in the notifications of the Patient Safety
Centers (NSP) of the country's health services 6.
Thus, the research aims to eluci=
date
the role of nurses in the care of the patient affected by pressure injuries=
in
Intensive Care Unit (ICU) beds.
METHODS
It is a bibliographic study of t=
he
integrative literature review type which, for its realization, were followed
the following steps: identification of the theme and selection of the quest=
ion;
Establishment of inclusion and exclusion criteria for studies in the
literature; Definition of information to be extracted from selected studies;
Evaluation of the studies included and presentation of the review/synthesis=
of
knowledge⁵.
The following guiding question,<=
span
style=3D'mso-spacerun:yes'> was considered based on this princ=
iple:
What is the role of nurses in caring for patients with pressure injuries in
Intensive Care Unit (ICU) beds? So articles were selected from 2015 to 2019=
, in
the databases of Latin American Literature/LILACS, Databases in Nursing/BDE=
NF,
and Medical Literature Analysis and Retrieval System online/MEDLINE in the
languages: Portuguese, English, and Spanish. The inclusion criteria adopted
were: articles published in Portuguese, English, and Spanish with the full
texts available in the selected databases. The exclusion criteria were:
articles in which it was not possible to identify a relationship with the
theme, editorials, articles of review, and texts that required payment to
access. The following descriptors crossed with the Boolean marker
“AND” were used: Nursing, pressure injury, Intensive Care Unit;
Nursing, Pressure ulcer, Intensive and Care Unit and Enfermería,
Presión ulcer, Intensive Care Units.
A flowchart of the article selec=
tion
process was formulated, in order to facilitate the understanding and help t=
he
construction of this study. The strategies used to search for articles were:
Inclusion of descriptors; Identification of databases and papers with relat=
ed
topics; Screening (repeated titles, unrelated themes, deleted after reading=
);
Eligibility and inclusion and exclusion criteria, based on the recommendati=
ons
of the checklist of the Statement for Reporting Systematic Review and
Meta-Analyses of Studies – PRISMA⁷.
The articles were read in full f=
or
descriptive and careful analysis. Then, the information from the studies ta=
ught
was structured in an instrument created that included: authors, title,
objective, year, and periodical. Meanwhile, the other instrument used inclu=
ded:
title, research methodology, level of evidence, and synthesis of results.
To categorize the evidence level,
the type of study was considered, using a hierarchical classification into
seven levels: level I: Evidence of a systematic review or meta-analysis of =
all
relevant Randomized Clinical Trials (RCTs); level II: Evidence obtained from
well-planned RCTs; level III: Evidence from well-designed controlled trials
without randomization; level IV: Evidence from well-planned cases and cohort
studies; Level V: Evidence from systematic reviews of descriptive and
qualitative studies; Level VI: Evidence from unique descriptive or qualitat=
ive
studies; Level VII: Evidence of the opinion of authorities and/or reports f=
rom
expert committees⁸.
Due to the fact, it is an
integrative literature review, that study did not require the approval of t=
he
Committee for Ethics in Research, however, were considered ethical aspects =
as
the quote of the authors of the articles.
RESULTS
It is noteworthy that, based on =
the
crossing of descriptors in the selected databases, the initial research
resulted in 113 publications. After the inclusion criteria were classified,=
12
articles in Portuguese and English remained. 8 of them were excluded because
they did not meet the eligibility criteria previously established, thus lea=
ving
4 articles analyzed by reading in full text and included in this integrative
review.
In addition, (n=3D1) articles we=
re
found in the BDENF database, (n=3D2) in LILACS and (n=3D1) in MEDLINE. Are
predominant among publications the Portuguese (50%), English (50%) and Span=
ish
(0%) languages.
DISCUSSION
It
is noteworthy that the patient's stay in the Intensive Care Unit (ICU) make=
s it
vulnerable to various procedures that are developed to stabilize some clini=
cal
conditions thus, during this period of stay, Pressure Injuries may arise. I=
ts
occurrence is generally associated with a set of extrinsic factors such as
pressure, friction, shear, and humidity; and intrinsic factors such as the
nutritional deficit, presence of edema, age, immobility, and underlying
pathology 9.
It
is identified that after the analysis and the reading of the articles, the
importance of discussing this theme about care became evident, especially t=
he
elaboration and implementation of measures to prevent pressure injuries. The
application of the Braden Scale can become a great ally for nurses to incre=
ase
the quality of service provided to people with pressure injuries, as it all=
ows
knowing their profile and directing the systematization of care. In order to
become the use of the scale effect, the professional must be properly train=
ed,
ensuring that there are no limiting situations from the interpretations and
scores of the evaluators' scores. For an adequate assessment, besides a
structured approach, as in the case of Braden, clinical judgment is essenti=
al,
in which one does not replace the other 10. Thus, the application of the Br=
aden
Scale by the professional nurse directs the nursing interventions in the
prevention of Pressure Injury. =
It
is known that in the role of the nurse, adequate training is required to ca=
rry
out skills in action planning, starting with assessment, prevention, and
treatment, in addition to health education for patients and their families,=
to
improve the care provided, as well as the quality of life 11.
The
development of this type of injury entails numerous negative consequences t=
hat
reflect the physical and emotional suffering for the patient, in addition, =
it
increases the risk of complications and comorbidities in the short, medium,=
and
long term. For the health system, it results in higher costs associated with
the need for a prolonged stay in the service, as well as higher investment =
in
material and human resources for patient care ¹².
It was observed that nurses demand
adequate education to acquire skills concerning action planning, prevention,
and treatment, in order to improve the care provided, as well as the patien=
ts'
life quality. In this sense, the use of protocols in the management of nurs=
ing care
for patients with LP are important tools and have an impact on controlling =
the
incidence, reducing complications, length of stay, and reducing mortality
associated with LP, however, they present high costs for its design,
implementation, evaluation, and maintenance¹³.<=
/p>
It
is understood that protocols assume the position of facilitator of care, th=
ey
are routines and actions of care and management of health services or teams.
They are instruments created from evidence-based practice that allow care
according to the best options and have an impact on the better quality and
safer practices for the patient. Thus, nurses must be attentive to identify=
and
face situations that require new strategies that contribute to the quality =
of
care. It is considered a therapeutic scheme that guides the team regarding =
the
evaluation and application of the most appropriate treatment for the patien=
t's
comprehensive rehabilitation. The assessment must take into account the cau=
se,
time of existence, presence or absence of infection in the lesion, and must
follow a logical order of classification, choice of the appropriate dressin=
g,
accompaniment, and reassessment of the lesion, as well as the use of
classification patterns of risks that help preventing the occurrence of the=
se injuries,
which cannot be treated only from what is possible to be seen, comorbidities
and physiological changes, must be corrected in conjunction with local
treatment (14, 15).
It
is noteworthy that nurses have a fundamental role in the assessment and tre=
atment
of these injuries and must sensitize, encourage and train the team to follow
defined standards of treatment, they also have the responsibility to foresee
and provide human, material, and structural resources, and to implement
preventive measures so that we can have better results 16.
The
limitations presented were the number of current sources in the literature =
on
the subject, indicating the production of studies with higher evidence
methodologies in the area, which corroborate more specific results in nursi=
ng
care, from prevention and health promotion to continuity of a good quality =
of
life during the PL treatment.
CONCLUSION=
It is concluded that the nurse h=
as a
crucial role both in the treatment of pressure injuries, as well as in the
choice of the most appropriate treatment and in the application of measures=
to
prevent these injuries. Nurses must know the process that involves the
treatment of the patient and that they develop a care protocol for patients
with pressure injuries and that the entire team involved can follow the same
standards of assessment and treatment.
It was evident that the analysis=
of
the studies provided a reflection on the importance of nursing actions in
customer care in the treatment of pressure injuries, as it demonstrates that
their performance enables negative impacts, from the maintenance of health =
to
the prevention of more severe complications. The studies identified were mo=
stly
from international publications, and even though the articles included are =
in
Portuguese and English, Brazil's deficiency in investing in knowledge of how
nurses work in this scenario is noticeable, as well as the need for levels =
of
evidence for greater confidence that publications are as close to reality as
possible. It should be noted =
that
the limitations presented were the amount of current sources in the literat=
ure
on the subject, indicating the production of studies with higher evidence
methodologies in the area, which corroborate more specific results in nursi=
ng
care, from prevention and promotion of health to continuity and good qualit=
y of
life during the PL treatment.
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Mayra Eloisa da Silva Endereço:
Avenida João Bartolomeu Torres, Cidade Jardim, Caruaru/PE, Nº74=
5,
CEP 55021- 280 Celular: (+55) 81.99877-3058 email: mayra-_eloisa@hotmail.com
2021-07-06 =
: 2021-08-28=
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