Clinical evidence of the nursing diagnosis Adult pressure injury.

Cássia Teixeira Dos Santos,Miriam De Abreu Almeida,Isabella Duarte Vidor,Franciele Moreira Barbosa,Thayná De Almeida,Amália De Fátima Lucena

doi:10.1590/1980-220x-reeusp-2021-0106

Abstract

To identify clinical evidence of the nursing diagnosis Adult pressure injury. Cross-sectional study with 138 adult patients, with community-acquired or hospital-acquired pressure injuries, admitted to clinical, surgical, and intensive care units. Data collected from Electronic health records (EHR) and from the clinical assessment of patients at the bedside, analyzed through descriptive statistics. The partial thickness loss of dermis presenting as a shallow open ulcer, intact or open/ruptured blister, consistent with a stage II pressure injury, was the significant defining characteristic. Significant related factors were pressure on bony prominence, friction surface, shear forces, and incontinence. The population at significant risk was that at age extremes (≥60 years). Significant associated conditions were pharmacological agent, physical immobilization, anemia, decreased tissue perfusion, and impaired circulation. The clinical indicators assessed in the patients showed evidence of the nursing diagnosis Adult pressure Injury, with significant lesions consistent with stage II, resulting from pressure, especially in elderly individuals, and in those on various medications.

Highlights

Pressure injury (PI) is an adverse event and a nursing indicator denoting low quality of care[1,2,3]
The partial thickness loss of dermis presenting as a shallow open ulcer, intact or open/ ruptured blister, consistent with a stage II pressure injury, was the significant defining characteristic
It was noticed that the Nursing Diagnosis (ND) Adult pressure injury lacked clinical studies to determine the level of evidence LOE-3, determined by the NANDA International (NANDA-I) taxonomy as an extremely important level to obtain testing and clinical proof of the ND falling in this classification[13]

Summary

Introduction

Pressure injury (PI) is an adverse event and a nursing indicator denoting low quality of care[1,2,3]. It shows high rates of prevalence in patients admitted to intensive care units (ICU), with a variability between 8 and 23% of cases, depending on patient severity and the risk factors presented[2,3]. Pressure injury represents the third most expensive health problem for health systems, third only to cancer and cardiovascular diseases[8,9]. Both prevention and proper treatment of PI shall be prioritized by nurses, who are responsible for patient care 24 hours a day. It was noticed that the ND Adult pressure injury lacked clinical studies to determine the level of evidence LOE-3, determined by the NANDA-I taxonomy as an extremely important level to obtain testing and clinical proof of the ND falling in this classification[13]

Methods

Results

Discussion

Conclusion