Introduction

The injuries caused by pressure (LP) constitute a challenge for the health services, because its occurrence is considered an indicator of the quality of nursing care provided to patients.¹

With this, its emergence has implications both for whom develops, as well as for the institution where the patient is hospitalized. Because, in addition to causing pain and discomfort, it can delay the recovery process, and also increase the rates of infections, which corroborates with the extension of the period of hospitalization, with the increase of expenses demanded by the treatment of the disease and also with the requirement for greater time of the nursing team for the provision of care.^2-3

It is advisable to consider that the LP is defined as an injury which is located in the skin and/or underlying tissue, resulting from intense pressure and/or prolonged or pressure in combination with shear stress.⁴Thus, in the context of Intensive Care Unit (ICU), due to the restrictions imposed on patients, associated with severe clinical conditions and therapies of greater complexity, patients become vulnerable to develop it.⁵ Therefore, the adoption of preventive measures should be prioritized by the nursing staff, since it is a practice that reflects the quality of care.⁶

Facing this scenario, with the aim of qualifying the care in health, the Ministry of Health (MOH) published on the first day of April 2013, the Ordinance N 529, which established the National Program for Patient Safety (PNSP), which is composed of six axles for the prevention of damage, among them the prevention of injuries caused by pressure.⁷ Furthermore, historically, various bodies have contributed to the strengthening of knowledge and the targeting of care outside the LP, as the North American organization National Pressure Ulcer Advisory Panel (NPUAP), dedicated to the prevention and treatment of these lesions.⁴

In spite of all the scientific production, the international literature points to the high incidence of LP, mainly in the ICU, which varies from 25.6% to 28.6%.^8-9Yet, it is estimated that approximately 600 thousand patients in hospitals evolve to death every year in the United States, as a result of complications secondary to LP.¹⁰ Although there are few epidemiological data in Brazil, recent studies show high rates of occurrence of skin lesions as the LP in patients in intensive therapy, which vary from 11% to 22%.^1-2,11

In the face of such incidences, it is emphasized that the nursing team should aim not only to clinical stability in patients and their high, but also the decrease of complications, such as the formation of this lesion, which is more susceptible to be developed in critical patients.¹² It is the competence of the nurse for risk management, through the implementation of strategies for the prevention of damage to patients, which should aim at the elimination of risks and the minimization of harmful processes.¹³

The fact of the LP be avoidable in more than 95% of the cases, instilled the interest in conducting this study, once the nurse is the professional who is ahead in patient care. In addition, there is a scarcity of studies that evaluate the practice of nurses in preventive care of LP, which reinforces the interest of this research. In addition, the studies related to the conduct of nursing forward the prevention of LP are not performing/omission of care, which in some cases are not perceived by nursing staff.¹⁴ In this sense, the identification of care prescribed and performed by nurses, as well as the factors that facilitate and inhibit this practice in the scenario of the ICU can contribute, not only with other studies, but also with the elaboration of protocols that come to the meeting of the programs and the reality experienced by professionals.

Forward to this question: what are the strategies for prevention of LP implemented by nurses during the assistance to patients admitted to an ICU?

This perception, the present study aimed to characterize the population studied and describe the interventions of nurses for the prevention of injury by pressure in an adult intensive care unit.

Method

A cross-sectional descriptive survey, conducted in an adult ICU of a medium sized hospital, in the region of the western border of Rio Grande do Sul (RS). The data collection occurred in the period from August to September 2017. For greater accuracy, it was initially performed a pre-test with a nurse who had experience in the sector under study, with the application of the instrument for data collection, for their subsequent adaptation.

For data collection, we applied a self-administered questionnaire developed by the researchers, from a survey conducted by means of published studies relating to the theme of research. This survey was based on the pursuit of scientific articles5,12,15-16 in the database of the Latin American and Caribbean Literature in Health Sciences (LILACS). For the pursuit of the productions, we used the keywords "Pressure Ulcer" and "Intensive Therapy Units". Also, were used as grounding the protocol of MS¹⁰ and other studies^2,17relevant to the theme.

From the literature review and current studies, was drawn up the instrument. Its first part was composed of issues relevant to the demographic characterization and training of participants, among them: sex, date of birth, titration, and year of training, time of work in nursing and in intensive therapy. The second part consisted of closed questions and dichotomous variables, such as the following: In the ICU, do you consider important the implementation of preventive measures for LP? Do you identify situations of risk for development of LP in patients hospitalized in their work unit? Do the evaluation of the patient and the identification of risk factors for LP help prevent them? Do you consider it important to develop and implement a prevention plan based on risk to individuals identified with risk of LP?

Also the questionnaire consisted of multiple choice questions, for example: mark on the basis for the care carried forward the prevention of LP in the ICU; pointing the interventions aimed at the prevention of LP that are performed during the assistance to the patient hospitalized in the ICU; identify the preventive measures prescribed for the nursing team in the ICU; highlight the factors that are considered as complicating factors for the implementation of preventive measures for LP in ICU and the factors that are considered as facilitators for the implementation of preventive measures for LP in the ICU.

Participated in this study all nursing professionals that comprised the ICU staff, totaling 13 (100%), which met the eligibility criteria: being a nurse in ICU and not be on vacation or license of any kind. The instrument was applied directly to the nurses in the hospital during the working hours of each professional, answered individually, and took place at a single time interval, through voluntary participation that occurred after the consent and signing the Informed Consent Form (ICF).

After data collection, the same were organized and inserted with dual typing, in a spreadsheet in Microsoft Excel 2010®, and comprised a database. For the analysis of the data obtained, we used the software Statistical Package for Social Sciences (SPSS), version 23 for Windows®. For descriptive analysis, we used the frequency distribution of, measures of central tendency and dispersion, and to describe the interventions of nurses from the prevention of LP, we used the distribution of frequency.

For the realization of this research, after the authorization of the institution of the field under study, delivered the project for consideration by the Committee for Ethics and Research Committee (CEP) of the Integrated Regional University of High Uruguay and Missions (URI) campus Santiago-RS, which was approved under the CAAE N 71476017.6.0000.5353. By involving humans, the survey was conducted in accordance with the ethical standards required by Resolution nº. 466 of 12 December 2012 of the National Health Council that regulates this type of study.

Results

In the complex intensive care unit of the hospital researched, participated in the survey 13 nurses, so that 11 (84.6%) were female and two (15.4%) of the male sex. Regarding the age range, the mean age was 29.9 years, with standard deviation (SD) of 6.5 and with the minimum and maximum values, respectively, 22 and 46 years.

With respect to the time of formation, the calculation of the median was five years old. As to the level of training of professionals, the survey revealed that seven (53.8%) had undergraduate and six (46.2%) were post-graduates. When approaching the time of work in nursing, we obtained the average of 70.4 months and median of 59 months, with SD of 77.6, with minimum and maximum values, respectively, between five and 289 months. In the sector of intensive therapy, the work of professionals was between two to 102 months.

When approached about their knowledge and their attitudes in relation to the prevention of LP in ICU, unanimously the participants pointed out that identify risk situations for the development of these lesions in patients in intensive care. In addition, the nurses pointed out how important the application of preventive measures, such as: patient assessment, identification of risk factors and implementing a plan of prevention of LP based on the risks presented by the patients.

In question on the basis used to provide nursing care to prevention of LP in the ICU, could choose more than one answer, and 76.9% of the participants marked the option 1- care is based on your knowledge; 84.6% chose the option 2- care is based on its scientific basis; and equal percentage selected the option 3- care is based on the institutional protocol. It is noteworthy that no nurse noted the option 4- do not realize care directed to the prevention of LP.

Subsequently, applied questions with multiple answers, with the aim of identifying the main measures related to prevention of LP that were performed by nurses during the critical patient care in the ICU. In this way, the Table 1, below, shows the interventions that nurses reported use to prevent the LP.

Table 1: Nursing interventions performed by nurses to prevent pressure injury in an intensive care unit.

*Variables^()**	N	%Cases
Evaluation of the activity-mobility of patients	13	100
Cerebrospinal-foot physical examination at the admission of all patients	13	100
Application of the Braden Scale	12	92,3
Daily skin inspection under and around medical devices	12	92,3
Daily skin inspection of all patients	11	84,6
Adherence of institutional strategies for LP prevention (protocols, routines, standard operating procedures)	10	76,9
Identification of the patient prone to LP development	10	76,9
Documentation and recording of patient evaluation results	8	61,5
Registration of repositioning regimes, frequency and position adopted	8	61,5
Daily risk assessment of LP development in all patients	7	53,8

^(*)Question of multiple choices.

Note: The total respondent is 13 and the n corresponds to the number of times the alternative was marked.

The data in Table 2 show the main preventive measures for LP prescribed by nurses for the nursing team to perform the care to the patient hospitalized in the ICU.

Table 2: Nursing interventions for the prevention of pressure injury prescribed by nurses for the nursing team in the intensive care unit.

*Variables^()**	N	% Cases
Maintenance of the patient with hydrated skin (e.g.: Use of creams and moisturizing solutions)	13	100
Perform decubitus alternation, repositioning in bed every 2 hours or before, when necessary	13	100
Perform body hygiene	13	100
Use of pyramidal mattress	13	100
Use of protective barriers in the areas of bony prominences (e.g., use of hydrocolloid plaques)	12	92,3
Use of support surfaces for pressure relief	12	92,3
Pay attention to patients with urinary and/or fecal incontinence (clean skin immediately after incontinence episodes)	10	76,9
Clean Patient Maintenance	10	76,9
Hydration optimization (provide and promote adequate daily intake of liquids)	10	76,9
Keep clean linens and stretched sheets	9	69,2
Patient moisture management (e.g. keeping patient dry)	8	61,5
Prevent skin friction in patient management	8	61,5
Nutrition Optimization	7	53,8
Bed moisture management (e.g. changing bedding, keeping bed linen dry)	6	46,2

^(*)Question of multiple choices.

Note: The total respondent is 13 and the N corresponds to the number of times the alternative was marked.

With the aim of identifying the challenges encountered during the preventive care of LP, was asked about the factors that hindered the provision of care in the sector studied. Thus, in accordance with the exposed in Table 3, note the main difficulties identified.

Table 3: Hindering factors in the prevention of pressure injury in an intensive care unit.

*Variables^()**	N	%Cases
Lack of nursing records on patient assessments and preventive measures of LP adopted	10	76,9
Lack of human resources (insufficient number of professionals)	9	69,2
High complexity of patients admitted to the unit	8	61,5
Workload overflow	8	61,5
Large number of patients admitted to the unit	8	61,5
Lack of training and continuing education in the subject of LP prevention	7	53,8
Lack of time to carry out preventive measures	6	46,2
Little adherence of the nursing team for the application of preventive measures of LP	6	46,2
Deficient material resources (lack of suitable devices for LP prevention)	6	46,2
Inadequate completion of instruments for risk assessment of LP development	4	30,8
Little adherence of the nursing team to risk assessment of LP	3	23,1
Absence of instruments for risk assessment of LP development	2	15,4
Short-term workload	2	15,4

^(*)Question of multiple choices.

Note: The total respondent is 13 and the N corresponds to the number of times the alternative was marked.

In view of point which contributes to the provision of preventive care, questioned whether the factors that facilitated the prevention of LP in the researched unit. In this way, you can analyze the frequency in which these reasons were highlighted, as presented in Table 4.

Table 4: Facilitating factors in the prevention of pressure injury in the intensive care unit.

*Variables^()**	N	% Cases
Involvement of the nursing team in the process of preventive care of LP	12	92,3
Continuity of other nurses in the LP prevention process	8	61,5
Training and ongoing education in the subject of LP prevention	6	46,2
Nursing records on patients’ assessments and preventive measures of LP	5	38,5
Use and completion of instruments for risk assessment of LP development	5	38,5
Low number of patients admitted to the unit	4	30,8
Adequate human resources (sufficient number of professionals)	4	30,8
Adequate material resources and sufficient number for LP prevention	2	15,4

^(*)Question of multiple choices.

Note: The total respondent is 13 and the n corresponds to the number of times the alternative was marked.

Discussion

The research revealed that the profile of nurses, there was a predominance of young professionals, with a minimum age of 22 years and female professionals (84.6%). These data corroborate a study¹⁸ that evaluated the characteristics of nursing in Brazil, which was evidenced that this is a profession that represents more than one million and 100 thousand workers up to 40 years, i.e., predominantly young. Still, surveys confirm that the nursing team is female hegemonically.^18,14

In what refers to the titration, the study identified that nurses had formed a little while ago, with performance in nursing five months ago and lived in the ICU for at least two months. Still, it was found that the majority of professionals (53.8%) had only undergraduate studies, which emphasizes the importance of commitment to the formation of the professional profile since the academic period, because it is seen that the insertion in the fields may not require experience in this area, however, to develop their nursing practice, the needs of scientific knowledge.

In this context, a study that evaluated the profile of the nurse who acts in the ICU identified the possibility of finding both professionals with less experience, as well as those with experience in the profession, which enables the improvement of skills and decision-making. Furthermore, the authors reinforce the need of the quest for professional improvement by means of technical-scientific enrichment.¹⁹Therefore, it is understood that the quest for knowledge should serve as a foundation for a safe practice.

As regards the prevention of LP, note that the professionals recognize its importance and provide care backed in science and in institutional protocols, which contributes to an evidence-based practice and for the standardization of care. However, it should be noted that not all existing strategies that are usually implemented, which denotes the necessity of systematization of care. In the face of reality, points out that the nursing care are still based on individual knowledge which results, many times, in unstable and staple interventions.²⁰

The question concerning the strategies implemented by nurses from the prevention of LP proved that the physical examination on admission of patients and evaluation of motor activity and mobility were identified as the main interventions developed by these professionals. In sequence, the application of Braden scale, assessment of areas of the body under and around devices and daily inspection of the skin of patients, were the most chosen alternative, followed by other interventions. Thus, it was identified that the understanding of the professionals about the importance of adopting preventive measures which allow, in addition to the evaluation of skin conditions, the identification of possible risk factors.²¹ It is known, moreover, that the dependence for completion of requirements and the prolonged time in the same position may determine regions susceptible to pressures and to the development of skin damage, which makes the evaluation of the activity and mobility an important action for prevention.^11,22

Despite the understanding about the need of repositioning, one should also consider that the patient hospitalized in the ICU has characteristics that hinder the periodicity of the decubitus changes and contribute to the development of the LP, as the use of appliances and medical devices.²³ For this reason, it is the ability and competence of the nurse for the preparation of an individualized care planning.

Now, associated with the evaluation of the patient, nurses can use instruments to assist during the assistance as the application of scales, in order to identify patients prone to the development of LP. Front of the relevance of the use of instruments that evaluate the susceptibility that patients have to develop lesions, a review of the literature pointed out that the nursing intervention most often cited among the studies was the use of scales predicting risks.²¹Highlights the Braden scale as the most used, in which the values obtained allow professionals to deploy individualized strategies, according to the needs of each patient.10 Thus, its use should subsidize nursing care.⁵

Therefore, prevention strategies mentioned less frequently by the participants corresponded to the nursing notes, which includes the documentation of evaluations of patients, as well as the registry of repositioning, besides the physical examination and revision of the risk of LP, which indicates a weakness in the provision of care. In this context, a study showed the association of the occurrence of skin lesions to the nursing records were incomplete, such as the lack of completion of instruments of evaluation of the patient and the absence of checking of care and preventive measures undertaken.¹³ Yet, it is known that from the reassessment of the risks it is possible to adjust the strategies of prevention, according to the needs of each patient.¹⁰

Another relevant fact is the understanding of the professionals about the application of preventive measures of LP through the prescription of nursing, because 100% responded that prescribe the bodily hygiene, the hydration of the skin, use of pyramidal mattress and a change in decubitus with repositioning in bed every two hours. However, the management of moisture from the bedside and the patient, the prevention of skin friction (friction and shear stress) and the optimization of nutrition, understood the care less prescribed.

Considering the above, for the maintenance of the skin hydrated, is chosen by the nurses, the type of cover in accordance with the availability of the institution. The products used are the moisturizing creams and essential fatty acids, associated with adequate water intake. Furthermore, in relation to skin care, the institution offers hydrocolloid cards, which are used to protect the areas susceptible to development of LP. In this perspective, a review pointed out that the transparent film of polyurethane also was effective in the prevention of these injuries. Still, the transparent film was more cost-effective than the hydrocolloid in the prevention of LP.²³

Thus, the adoption of hygiene measures aims at keeping the skin clean and dry through the removal of moisture, which can be caused by sweating, deletions or intestinal and urinary drainage.21 The maintenance of hydration allows you to minimize the dryness of the skin, in addition, there are records of the efficiency of treatments of comfort for hydration and stimulation of movement, but it should be avoided in areas of protuberances.²¹

It is known that the surfaces of support can include beds and mattresses of low and high technology, pillows and cushions designed to protect vulnerable parts of the body and redistribute the pressure of the surface evenly and are measures that help to reduce the risk of LP.23 In fact studied, it was identified that nurses recognize and prescribe the use of pyramidal mattress foam, as a preventive measure of LP. In this perspective, a study24 concluded that the use of specific alternating pressure mattresses geared toward the prevention of LP is valid when compared to the use of standard mattresses. Thus, the same study emphasizes the existence of support surfaces of low and high technology, however, the lack of high-tech surfaces studied in reality becomes a limitation. The repositioning is described as a form of prevention of LP more known and used by nursing.^6,25 In addition, the management with the patient requires care, because you must prevent the skin friction that occurs from the friction and shear, in order to prevent skin lesions.21 However, there are still omission of this care, a fact which goes to meet a study that identified that the repositioning of the patient every two hours or as needed, it was omitted by 50 (31.1%) of nurses.¹⁴ Book also identifies the importance of supervision of the nurse forward the implementation of preventive measures for LP, from the continuous evaluation of care prescribed.

Regarding the patients’ nutritional intake, emphasizes that inadequate nutrition can influence the development of LP, because a body under these conditions presents alterations in oxygen transport and metabolism.²² Yet, one study showed that the protein intake of the patient should be assisted with greater rigor, because it is associated with the prediction of LP.¹¹ From this perspective, the adequate nutrition should be an item considered in the prevention and for this reason, there is a continuous monitoring regarding this aspect that favors the assessment of nutritional status and the readjustment of the needs of each patient.

This study showed that nurses apply some strategies with greater frequency, while others were less observed which has also been demonstrated in the literature. In an investigation pointed out that, to relate measures envisaged by the protocol of MS with those used by nurses, the measures more applied comprised the most simple and usual, as the alternation of decubitus, minimizing pressure and physical examination of the skin. In view of this, it is the existence of recommendations for risk low, moderate and high.²⁵ In this sense, studies show that the risk for the development of LP in patients hospitalized in the ICU varies from moderate to high.^6,2,11With this, emphasizes the importance of knowledge about the preventive measures valid, with the aim of applying them according to the risk presented.

In addition, realize that the risk presented by the patient critical is greater and wonders why the nurses are usually low-risk measures. Therefore, it is emphasized that the etiology of LP is a multicausal.¹ Thus, are factors that potentiate the risk of complications in critically ill patients, such as the clinical status, the comorbidities and the hematological profile and metabolic aspects.² Thus, in spite of the factors related to patients are more difficult to be worked out, exposure to external factors can be minimized from the management of sources that cause pressure forces, therefore, the development of LP indicates the quality of nursing assistance.²²

Not all nurses marked this understanding, the alternative pertaining to the implementation of the identification of the patient with risk of development of LP. Considers that the LP can be avoided, from training the team regarding the identification of risk factors.¹ Thus, it is observed that the skin lesions caused by the pressure does not comprise only the factors associated with nursing care, because it must also consider the factors inherent to the patient, however, the recognition of which are risk will allow the team to give greater attention to preventive measures.

Still, it is known that the best strategy of prevention is early intervention that is based on the identification of patients and the deployment of preventive methods.¹³ In this context, it was not possible to evaluate the relationship between the nurses' knowledge about the preventive measures with those that are carried out. However, the data obtained demonstrate the shortcomings related to the care they are exempted. For this reason, a study suggests the existence of a deficit of knowledge of the nursing team and, mainly, of nurses on the prevention of LP,¹⁷ in addition, shows that, perhaps, lacking a greater interest of professionals in improving the knowledge and effective in their behaviors.²¹

To do so, you need to identify and work the limitations encountered in practice, being that, the main difficulties identified were related to the lack of nursing records and lack of human resources, in addition to the lack of training and permanent education about prevention of LP and limitations of material resources. Considering the above, the support of the management it is important, given that there is a need for provision of adequate material resources, staff dimensioning and education of professionals.22 Therefore, it is seen that part of limitations does not depend exclusively of nurses, however, it is known that these professionals are important in the process of management of resources.

In agreement with the findings, a study attributed the omission of the care factors related to human resources, which highlighted the insufficient number of professionals, followed by material resources and communication. This is relevant to nursing managers who want to implement measures that make opportune the strengthening of human resources, with the quantity and the skills necessary to provide continuous assistance, in accordance with the needs of patients, in addition to avoiding carefully omitted and its impact on the results of attention.¹⁴

The involvement and continuity of care provided by the nursing team in the process of prevention of LP understood the main facilitators mentioned by participants. With this, it is emphasized that the preventive care of these lesions permeates through the understanding of their importance and includes pipelines for a dignified care, with actions based on evidence.²¹Thus, in addition to the search for scientific recommendations, the nurse should assume its responsibilities as the competence for the development of the systematization of nursing assistance.²⁰Therefore, emphasizes the importance of awareness of professionals.

After the completion of the study, it is acknowledged as limiting the size of the population, since it is a unit of a hospital in the countryside, which has as characteristic the smaller size, which does not allow the generalization of the results. In addition, it is considered as limiting the non-inclusion of nursing technicians, which also act in the provision of care and direct care to patients. Thus, further research may be reproduced, in order to increase the investigations concerning the topic.

It is, above all, the relevance of this study, which enabled us to recognize the reality of ICU of an institution of the interior, through the analysis of the profile of nurses and the actuation of these in the prevention of LP. In addition, made opportune identify the difficulties and facilities found for the provision of preventive care, data that does not show outlying described in national and international literature.

In the perspective of a viable quality assistance and secure to the patient, it is suggested the implementation of prevention protocols based on identification and management of risks, in addition to the implementation of a plan of care with preventive measures valid, toward the standardization of care and awareness of professionals regarding interventions.

Conclusion

The study reinforces that nursing is a profession whose age range of exercise is predominantly young and, with this, there is the possibility of finding, both professionals with less experience, as well as those with greater experience in the profession. In addition, it is seen that the insertion in the fields may not require experience in this area, however, to develop their work in a safe manner, the nursing needs of scientific knowledge. Therefore, it is understood that, regardless of the time of action, the quest for knowledge should be continuous and serve as a foundation for a safe practice and based on scientific evidence, in order to provide quality assistance.

The main results show that the strategies usually adopted by nurses for the prevention of LP is confined to a few interventions, despite the existence of studies about the preventive measures and the association of the occurrence of lesions with the quality of care provided. This fact makes reflect the behavior of nurses who must be backed up scientifically to be offered the main measures of prevention that include simple but effective care.

References

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Corresponding author

Rigielli Ribeiro Manganelli

Address: Rua Walter Jobim, 388, Manoel Viana, Rio Grande do Sul.

Email: rigiellimanganelli@hotmail.com

Authorship contributions

1- Rigielli Ribeiro Manganelli

Conception, planning and presentation of the research project, conducting the literature review, elaboration and development of the instrument used to obtain data, and application of the data collection instrument with the research participants. Analysis and interpretation of data, writing and critical revision of the text.

2- Raquel Soares Kirchhof

Conception and planning of the research project, assistance in the elaboration and review of the instrument used to obtain data, as well as participation in the analysis and interpretation of the data obtained, participation in the development of writing and critical revision of the text.

3- Greice Machado Pieszak

Evaluation of the planning of the research project, the instrument used to obtain data, the interpretation of the data obtained participation in the development of the writing and the realization of the critical revision of the text.

4- Carla da Silveira Dornelles

How to cite this article

Manganelli RR, Kirchhof RS, Pieszak GM, Dornelles CS. Nurses’ interventions in preventing pressure injury in an intensive therapy unit. Journal of Nursing UFSM. 2019 [Access in: 2019 Jun 15]; vol e41: pi-p21. DOI: https://doi.org/10.5902/2179769233881