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PREVALENCEOFPRESSUREULCERSININTENSIVECAREUN1.pdf
Medeiros LNB de, Silva DR da, Guedes CDFS et al. Prevalence of pressure ulcers in intensive...
English/Portuguese
J Nurs UFPE on line., Recife, 11(7):2697-703, July., 2017 2697
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.10939-97553-1-RV.1107201707
PREVALENCE OF PRESSURE ULCERS IN INTENSIVE CARE UNITS PREVALÊNCIA DE ÚLCERAS POR PRESSÃO EM UNIDADES DE TERAPIA INTENSIVA
PREVALENCIA DE ÚLCERAS POR PRESIÓN EN UNIDADES DE TERAPIA INTENSIVA Luan Nogueira Bezerra de Medeiros1, Deyvisson Ribeiro da Silva2, Cintia Danielle Faustino da Silva Guedes3,
Thuanne Karla Carvalho de Souza4, Belisana Pinto de Abreu Araújo Neta5
ABSTRACT
Objective: to detect the prevalence of Pressure Ulcers (PUs) in patients admitted to Intensive Care Units (ICUs). Method: cross-sectional, quantitative study, developed in an emergency and trauma reference hospital in the State of Rio Grande do Norte located in the eastern sanitary district of Natal (RN), Brazil. Results: the prevalence found of PUs was 69% in the four ICUs. Individually, the Cardiac ICU had an incidence of 44.4%; the Bernadete ICU, 85.7%; the General ICU, 60%; and the Emergency ICU, 87.5%. Conclusion: It is necessary to focus on a strategic planning for prevention and treatment measures to reduce the PU indexes in the institution. Descriptors: Nursing; Pressure Ulcer; Intensive Care Units; Prevalence.
RESUMO
Objetivo: detectar a prevalência de Úlceras por Pressão (UPs) em pacientes internados em Unidades de Terapia Intensiva (UTIs). Método: estudo transversal, de abordagem quantitativa, desenvolvido em um hospital de referência para o estado do Rio Grande do Norte em urgência e trauma, situado no distrito sanitário leste do município de Natal (RN), Brasil. Resultados: a prevalência encontrada de UPs foi de 69% nas quatro UTIs. Individualmente, a UTI Cardiológica apresentou 44,4%; UTI Bernadete, 85,7%; UTI Geral, 60%; e UTI do Pronto-Socorro, 87,5% de prevalência de UPs. Conclusão: é necessário nortear um planejamento estratégico para medidas de prevenção e tratamento para redução dos índices de UPs na instituição. Descritores: Enfermagem; Úlcera por Pressão; Unidades de Terapia Intensiva; Prevalência.
RESUMEN
Objetivo: detectar la prevalencia de Úlceras por Presión (UPs) en pacientes internados en Unidades de Terapia Intensiva (UTIs). Método: estudio transversal, de enfoque cuantitativo, desarrollado en un hospital de referencia para el estado de Rio Grande do Norte en urgencia y trauma, situado en el distrito sanitario este del municipio de Natal (RN), Brasil. Resultados: la prevalencia encontrada de UPs fue de 69% en las cuatro UTIs. Individualmente, la UTI Cardiológica presentó 44,4%; UTI Bernadete, 85,7%; UTI General, 60%; y UTI de Pronto-Socorro, 87,5% de prevalencia de UPs. Conclusión: es necesario guiar un planeamiento estrategico para medidas de prevención y tratamiento para reducción de los índices de UPs en la institución. Descriptores: Enfermária; Úlcera por Preisón; Unidades de Cuidados Intensivos; Prevalencia. 1Nurse, Post-graduation in the Multiprofessional Residency Program in Maternal and Child Nursing, Federal University of Rio Grande do Norte/UFRN. Santa Cruz (RN), Brazil. Email: [email protected]; 2Nurse, Postgraduate student in Urgency and Emergency, Estácio Ponta Negra Faculty. Natal (RN), Brazil. Email: [email protected]; 3Nurse, Post-graduate student in Public Health, Estácio Ponta Negra Faculty. Natal (RN), Brazil. Email: [email protected]; 4Nurse, Post-graduate student in Public Health, Estácio Ponta Negra Faculty. Natal (RN), Brazil. Email: [email protected]; 5Nurse, Professor, Nephrology Specialist, Estácio Ponta Negra
Faculty, Natal (RN), Brazil. Email: [email protected]
ORIGINAL ARTICLE
Medeiros LNB de, Silva DR da, Guedes CDFS et al. Prevalence of pressure ulcers in intensive...
English/Portuguese
J Nurs UFPE on line., Recife, 11(7):2697-703, July., 2017 2698
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.10939-97553-1-RV.1107201707
Pressure ulcers (PU) are caused by the
pressure exerted on the skin and underlying
tissues of a prominent bone. The National
Pressure Ulcer Advisory Panel (NPUAP)
presented in 2014 a new classification for PUs.
Based on the severity of the PU in the skin,
this can be classified in the following stages:
stage I (intact skin with non-blanchable
erythema); stage II (partial loss of skin
structure or blister); stage III (full loss of skin
structure with visible subcutaneous tissue);
stage IV (full loss of tissue with exposed
muscle and bone structure); unstageable
(total loss of skin structure or tissues of
unknown depth); and suspected deep lesion (a
dark red or purple area located on intact skin
or blister filled with blood)..1
The indexes of Pressure Ulcers (PUs) in
some countries of the world are much lower
than in Brazil. In China, a study identified a
prevalence of 1.58% and incidence of 0.63%.2
In Iranian hospitals, two prevalence rates
were obtained in Intensive Care Units (ICUs):
26.7% for patients followed daily, and 19%
based on medical records reviewed.3 In India,
the prevalence was 3.1% in nursing wards.4
PUs represent a problem for hospital and
public health institutions.5 They incur
financial costs to health services, as for
example with industrialized dressings.6-7 They
also indicate the quality of health care
regarding patient safety, since low PU rates
are related to good care provided.8-9
Intensive care patients are prone to factors
strongly associated with PUs, such as: sepsis,
long hospital stay and high risk on the Braden
scale.10 They may lead to impairment of the
clinical condition of critically ill ICU patients.9
Individuals with PU need care from the
multiprofessional team working in the sector,
with emphasis to the Nursing Team, as this is
the one that stands out for the continuous
care 24 hours a day.6
Nursing plays an important role in the
prevention and treatment of PUs. In this
context, the use of indices to classify these
lesions has been associated to a quality
nursing care,11 and one form the nursing team
can act to help is by applying preventive
protocols to reduce high rates of PUs.9
In this context, considering the PU indexes
as a public health problem and an aggravating
factor for the health of ICUs patients, the
present study aimed to detect the prevalence
of PUs among patients hospitalized in ICUs of
a reference hospital in Rio Grande do Norte
(RN).
This is a cross - sectional study with
quantitative approach developed in an
emergency and trauma reference hospital in
the State of the RN, located in the eastern
sanitary district of the Municipality of
Natal/RN. The institution has five ICUs:
Cardiac ICU (10 beds); Bernadete ICU (10
beds); General ICU (9 beds); Emergency ICU
(10 beds); and Pediatric ICU (6 beds).
The inclusion criteria for detecting the
prevalence of PUs in patients admitted to the
ICUs were: hospitalization for at least 24
hours; signing of the Informed Consent Form
(ICF) by a responsible person in the case of
unconscious patients; age equal or above 18
years. Exclusion criteria were: time of
hospitalization less than 24 hours due to
discharge; death or transfer to a sector other
than ICU; pediatric ICU; and patients aged less
than 18 years.
Four ICUs were included in the research.
They have 39 beds intended for the care of
patients with varied etiologies and clinical and
surgical conditions.
Data collection was done by completing a
structured form. The collection was
conducted by the researchers at the moment
when the nursing professionals were bathing
the patient in the bed, a proper moment for
identification, evaluation and classification of
ulcers.
The collected data was transferred to a
Microsoft Excel 2007 worksheet and exported
for analysis in the Statistical Package for
Social Science, version 15.0 (SPSS) to be
analyzed, and stratified into figures, Figures
and tables.
The prevalence of PUs was determined
according to the following calculation:
Number of patients with PU in the ICUs
Prevalence = ____________________________ x 100
Number of patients admitted to the ICUs
The prevalence coefficient can be defined
as the ratio of known cases of a given disease
and population. Thus, the result is multiplied
by the referential base of the population,
which is power of 10.12
The research respected the ethical
precepts of Resolution 446/2012 of the
National Health Council13, and after receiving
approval from the Ethics and Research
Committee (REC) of the University Hospital
INTRODUCTION
METHOD
Medeiros LNB de, Silva DR da, Guedes CDFS et al. Prevalence of pressure ulcers in intensive...
English/Portuguese
J Nurs UFPE on line., Recife, 11(7):2697-703, July., 2017 2699
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.10939-97553-1-RV.1107201707
Onofre Lopes - HUOL/UFRN under Opinion nº
1,255,711 and CAAE: 46268715.8.0000.5292.
On November 4, 2015, 37 of the 39 beds
were occupied, one was vacant and the other
was unavailable due to maintenance. The
study sample consisted of 29 bedridden
patients; two patients were aged less than 18
years, two had been hospitalized for less than
24 hours and four patients were unconscious
patients whose responsible caregivers refused
to participate in the study.
Among the 29 (100%) selected patients, 20
(69%) presented at least one PU, and nine
(31%) had none. These data show a prevalence
of 69% of PUs in patients admitted to the four
ICUs.
Based on the overall prevalence of this
study, we stratified the results per ICU
studied. Nine (100%) patients from the Cardiac
ICU participated in the study; four
(prevalence of 44.4%) had PUs, and five
(44.6%) had no lesions. Seven (100%) patients
from the Bernadete ICU participated in the
study; six (prevalence of 85.7%) had PUs and
one (14.3%) had no lesions.
At the General ICU, five (100%) patients
participated in the study; three (prevalence of
60%) had PUs and two (40%) had no lesions.
And in the Emergency ICU, eight patients
(100%) participated in the study; seven
(prevalence of 87.5%) had PUs and one (12.5%)
had no injury. Figure 01 presents the overall
prevalence of PUs and the prevalence per ICU.
Figure 1. Overall prevalence of PUs in hospitalized patients, and prevalence
per ICU. Natal (RN), Brazil, 2015.
Regarding the sex of these patients, 24
(82.76%) individuals were male and five (17,
24%) were female. Analyzing males alone, 17
(70.8%) out of the of the 24 (100%) patients
presented PU and seven (29.2%) did not
present lesions. Among the five (100%)
women, three (60%) presented PU and two
(40%) did not present lesions.
Regarding the age group of the 29 (100%)
patients who presented or not PUs, the results
were as follows: three (10.3%) patients in the
age group between 18 and 25 years presented
PUs; two (6.9%) patients in the age group
between 26 and 33 years had PUs and two
(6.9%) had no lesion.
One patient in the age group between 34
and 41 years (3.5%) had PUs and another
patient (3.5%) had no lesions; there were no
patients between the ages of 42 and 49; two
(6.9%) patients in the age group between 50
and 57 years had developed the lesion and
two (6.9%) had not; 12 (41.3%) patients in the
age group equal to or greater than 58 years
were found with PUs and four (13.8%) were
not. The Figure 02 below presents the
incidence of PUs per age group.
Figure 2. Frequency of patients with and without PUs per age group. Natal
(RN), Brazil, 2015.
RESULTS
Medeiros LNB de, Silva DR da, Guedes CDFS et al. Prevalence of pressure ulcers in intensive...
English/Portuguese
J Nurs UFPE on line., Recife, 11(7):2697-703, July., 2017 2700
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.10939-97553-1-RV.1107201707
Regarding the length of hospitalization:
among patients hospitalized for 1 to 15 days,
10 (34.5%) had PUs and eight (27.5%) had no
lesions; among patients hospitalized for 16 to
30 days six (20.7%) had PUs and one (3.5%)
had no lesions; among patients hospitalized
for 31 to 45 days, one (3.5%) had PUs; among
patients hospitalized more than 46 years,
three (10.3%) were identified with UPs. Figure
03 presents the frequency of patients with
and without PU in relation to the length of
hospitalization in the sectors discussed.
Figure 3. Frequency of patients with and without PUs in relation to
the length of hospitalization. Natal (RN), Brazil, 2015.
In the evidence of the prevalence of PUs, it
was possible to quantify and classify these
lesions. Forty-two (100%) PUs were identified:
nine (21.4%) stage I PUs; 23 (54.8%) stage II
PUs; eight (19%) stage III PUs; and two (4.8%)
stage IV PUs.
The Sacrococci region was affected by 11
(26.2%) PUs. Of these, there were: one stage I
PU, two stage II PUs, six stage III PUs and two
stage IV PUs. In the Trochanter region, one
(2.4%) stage I PU was found.
In the Occipital region, there were six
(14.3%) stage II PUs; in the middle Ankle were
found two (4.7%) PUs, one stage I PU and one
stage II PU; in the Elbow region, two (4.7%)
PUs were found, one stage I PU and one stage
III PU.
Calcaneus PU corresponded to 18 (42.9%)
lesions, six of them being stage I PUs and 12
stage II PUs; there was also one case of PU in
the penis (2.4%), being a stage II PU; and the
ear region presented one (2.4%) stage II PU.
Figure 4 shows the frequency of PUs in
relation to their location.
Figure 4. Frequency of PUs in relation to their location. Natal (RN),
Brazil, 2015.
A study carried out in a university hospital
in the city of Botucatu/SP analyzed the 332
hospitalized patients from September 2007 to
August 2008 and indetified a prevalence of
PUs of 17.79%(14). In a city in the state of Rio
de Janeiro, the prevalence found was 22.9%
among 109 hospitalized patients from March
to May, 2010, in a federal hospital15
The research that presented the most
similar results to our present data, but still
with a notable difference, was the one
performed in a public hospital in the Federal
District. The total prevalence was 57.89%
among 19 patients on April 13, 2007. The
authors found the following prevalences per
DISCUSSION
Medeiros LNB de, Silva DR da, Guedes CDFS et al. Prevalence of pressure ulcers in intensive...
English/Portuguese
J Nurs UFPE on line., Recife, 11(7):2697-703, July., 2017 2701
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.10939-97553-1-RV.1107201707
each subunit: 50% in a general unit, and 87.5%
in a unit specialized in trauma. The result
found in the trauma unit of this study is
similar to the result of the current survey,
which also showed a prevalence of 87.5% in
the emergency ICU.6
Likewise in the current study, in the
research developed at the university hospital
of the city of Botucatu/SP, males were the
most affected by PUs. Among the patients
with PUs, 55% were male and 45% were
female.14 The age group equal to or greater
than 58 years presented the largest number of
people affected with PUs in the present study.
Age appears as a contributing factor for the
development of these lesions. It is notable
that aging slows the healing process and
vascularization, as well as decreases the
function of collagen; as an example, quick
healing of similar wounds is observed in
children as compared to an older people.16
According to the Figure 03 of the present
study, at least one patient hospitalized from
16 to 30 days did not present PUs, but no
patient in the group of 31 to 45 days remained
without injury. Thus, it can be said that a long
hospitalization time is a risk factor for the
development of PUs.10
As for the region most frequently affected
by PUs in the present study, the Calcanal
region prevailed (42.9%), followed by the
sacral region (26.2%). Another study identified
that the most affected area was the calcaneal
region, with nine occurrences, followed by the
malleolar and sacral regions with four and
three occurrences respectively. The data of
this research in relation to the most affected
site are comparable to those of current
research, presenting the calcaneal region as
the most affected, as well as the presence of
PU in the penile region, as well as in the
current study.6
The prevalence of PUs found in this study is
considered high in comparison to research
carried out in ICUs from other hospital
institutions in the country. This may be a
reflection of the quality of healthcare
provided at the institution or the lack of
implementation of preventive strategies, as
standard protocols.
The existence of PUs has repercussions on
stressful situations for health professionals,
specifically for the nursing team, as they are
responsible for the daily dressings and
preventive measures to maintain the patients'
skin integrity. All this responsibility, besides
other activities such as drug administration
and bathing in the bed, causes an excess of
work for this team and can represent a factor
that contributes to the formation of the
lesions. An overwhelmed professional may not
perform his duties with quality.
PUs affect the patient's health in physical,
psychic and emotional aspects; cause concern
among the family members regarding the
consequences that these lesions may have on
the affected individual; and incur a high
financial cost to the institution, which invests
in products for treatment.
Among the regions affected by PUs, the
lesion found in the penis is notable. No
research shows theoretical basis for the
formation of this type of ulcer, although this
lesion was mentioned in one study.6 The PU in
the penis can lead to consequences such as
penile dysfunction and partial loss of the
organ, depending on the staging of the lesion.
These consequences may cause negative
feelings and future frustrations to te patient.
In this study, we raise the hypothesis that
the lesion in the penis is the result of the
continuous use of a device for collecting
urine. More research on PUs in penile regions
is necessary in order to list which causes lead
to the occurrence of this type of injury.
Early use of plaque covers for protection in
the sacral region was observed and this area
was not predominant in the study. It is
possible to raise the hypothesis that the other
areas did not receive this preventive measure
and for that reason they developed PUs. The
calcaneal region was the most affected, and
during the collection of the data, the
erroneous form of cushion disposition for
protection of the calcaneus was observed.
These were placed directly in the region and
not letting the feet float.
Studying PU is always necessary, since this
injury is a frequent public health problem and
can influence the recovery of hospitalized
patients, specifically in ICUs. Further research
is needed to ascertain the magnitude of the
occurrence of these lesions in Brazil, because
scientific basis is fundamental to apply
optimal conducts for prevention and
treatment.
1. National Pressure Ulcer Advsory Panel. NEW
2014 Prevention and Treatment of Pressure
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2. Jiang Q, Li X, Qu X, Liu Y, Zhang L, Su C, et
al. The incidence, risk factors and
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Medeiros LNB de, Silva DR da, Guedes CDFS et al. Prevalence of pressure ulcers in intensive...
English/Portuguese
J Nurs UFPE on line., Recife, 11(7):2697-703, July., 2017 2702
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.10939-97553-1-RV.1107201707
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Medeiros LNB de, Silva DR da, Guedes CDFS et al. Prevalence of pressure ulcers in intensive...
English/Portuguese
J Nurs UFPE on line., Recife, 11(7):2697-703, July., 2017 2703
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.10939-97553-1-RV.1107201707
Submission: 2016/05/06 Accepted: 2017/05/25 Publishing: 2017/07/01
Corresponding Address
Luan Nogueira Bezerra de Medeiros Rua João Bianor Bezerra, 64, Ap, 305 Bairro Centro CEP: 59200-000 − Santa Cruz (RN), Brazil
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