Prevalence of Pressure Injury of Bedridden Patients , Hospitalized in a Public Hospital

Conclusion: The prevalence of pressure injury was high among bedridden patients, which shows the need of preventive measures, such as protocol implantation, use of scale of risk assessment, appropriate supporting surface, repositioning in bed, adequacy of dressings and instructions for patient discharge. Prevalence of Pressure Injury of Bedridden Patients, Hospitalized in a Public Hospital ORIGINAL


Introduction
Brazil is experiencing a period of demographic and epidemiological transition, as a result of urbanization, industrialization and advances in science and technology.It is possible to link these new characteristics of Brazilian society to lifestyles and high exposure to risk factors which have, over the years, provided some changes in the morbidity and mortality patterns, such as the high incidence of chronic degenerative diseases and automobile accidents.[1] As a consequence of these facts, it is common, observing the partial or total loss of physical mobility, the reduction of sensitivity and the occurrence of other injuries such as Pressure Injury (PI), thus constituting the main causes of disabilities, dependence on care, infection, hospitalization and deaths.[2] The pressure injury (PI), also known as a pressure ulcer, consists of the destruction of the skin layers and/or the underlying tissue and normally develops in areas of bony prominence, as an effect of a prolonged pressure or the combination of the pressure with friction and shear forces; it is classified in four stages, from 1 to 4, according to the depth of the injury and two unclassifiable situations -the deep tissue injury and the necrosis.[3] Considered as an adverse event to patient safety and a quality indicator of health care, PI represents a severe public health problem, due to its high incidence, prevalence and mortality coefficients, as well as some particularities in treatment, such as the need for surgical interventions, prolonged hospitalization and the high risk of infection.[4] Studies performed in the United Kingdom and Sweden have shown that the overall PI prevalence in hospitalized patients was approximately 15%.[5,6] In Brazil, this indicator tends to be higher, especially when it involves patients in intensive care, reaching the percentage of 57.9%.[7] In Piauí, the studies found prevalence data of PI with a variance of 13.3% to 40%.[8,9] The pressure injuries are considered complex wounds and very difficult to heal, due to the intrinsic and extrinsic factors related to their occurrence.The occurrence of skin injuries, regardless of their etiology, directly influences a person's health-related quality of life (HRQoL), since they can change the daily life activities, causing pain, suffering, fear, dependence, limitations, low self-esteem, anxiety and isolation.[10] The national literature confirms that the classification of patients at risk, the constant assessment of skin characteristics, the introduction of protocols and educational programs are indispensable in the prevention of PI [11].Given the seriousness of the PI occurrence, the Ministry of Health implemented the National Policy of Patient Safety in 2013, which has, as one of its goals, the validation of protocols, guides and manuals related to the prevention of pressure injury.[12] Consequently, primary care and home care reappear in the Brazilian scene as an alternative for prevention, evaluation and treatment of this injury.This practice aims to reduce incidence and mortality indicators and, as a consequence, increase the quality of life, since the presence of injuries enhances the development of temporary and permanent disabilities.[13] Based on the above considerations, this study aims to analyze the prevalence of pressure injury in bedridden patients, hospitalized in a public hospital in the city of Teresina, state of Piauí, Brazil.

Methods
This is a cross-sectional study conducted in a public hospital in Teresina, state of Piauí.The population consisted of 752 medical records of patients hospitalized in the healthcare and surgical centers, in 2013.
The inclusion criteria were: age of 18 years or more, period of hospital stay of more than 48 hours, prolonged immobility in the bed or chair, and PI report.Those patients, who did not have records with mobility conditions were excluded.After reading all the medical records, 86 records were selected, for they included a history of prolonged immobility throughout the hospitalization period and, from these records, 27 presented PI, thus constituting the non-probabilistic and intentional sampling.
The data collection took place in April and May, 2014, through a semi-structured instrument consisting of two parts: The first one comprised socio-demographic data, such as age, sex and education.The second one corresponded to the clinical variables, including bedridden time, cause of hospitalization, associated co-morbidities, number of injuries, anatomical location, stage and coverings used for prevention and treatment of the lesions.
The data collected were registered into databases, with double typing in Microsoft Excel spreadsheet, in order to identify and correct possible typing errors.Afterwards, the data were processed by Statistical Package for the Social Sciences (SPSS) software, version 17.0; then, the descriptive statistics were calculated, such as means and standard deviation for quantitative variables, and frequencies for qualitative ones.
In order to calculate the prevalence, the number of bedridden patients who developed pressure lesions was found, and divided by the number of bedridden patients hospitalized in the healthcare and surgical centers, in the year of 2013.
This study met all the requirements of the Resolution 466/12 of the National Health Council, and the favorable opinion to its accomplishment was issued by the Research Ethics Committee of the State University of Piauí, under process n o .535,179.

Results
From the total number of 752 patients admitted to the healthcare and surgical centers in 2013, 86 patients (11.4%) were bedridden and 27 (3.6%)presented PI.Considering the sample of bedridden patients, the prevalence of pressure injury corresponded to 31.4%, with a predominance of males (77.8%), as well as elderly (81.5%), with a mean age of 68.5 years (SD = 16.6).
In Table 2, we can verify that: the duration of the injuries was not recorded in most of the medical records (88.9%), the anatomical location that most affected the patients in the bed was the sacral region (77.8%), a great part of PIs has no stage des-

Discussion
According to the sociodemographic characteristics of the studied population, we can verify the predominance of the injuries in males (77.8%), corroborating a study conducted in Piauí that, when analyzing the clinical conditions of bedridden patients under home care, also showed the PI prevalence in males.[13] The prevalence in males is the result of the difficulty of repositioning the patient due to their overweight, as well as an increased exposure to risk factors and the lower demand for health services.[14] The highest frequency of pressure injuries was observed in the elderly, with a mean age of 68.5 years (SD = 16.6) and with sequelae of circulatory and neurological diseases.This result is justified by the physical limitations and the greater predisposition to chronic diseases, related to the aging process, which increase the occurrences of some complications such as prolonged immobility and sensitivity loss or decrease.[15] The chronic situations, when associated with an advanced age, constitute risk factors involved in the pathophysiology of PI, which are increased face to prolonged immobility and hospitalization conditions, which may worsen the health situation and elevate the cost of the treatment.
Additionally, the elderly present an increase in co-morbidities and healing time, reduction in skin elasticity and texture, in the frequency of cell replacement, in mobility, as well as a reduction of lean mass, leading to exposure of bony prominences and favoring the development of PIs.[17] Regarding the reason for being bedridden, we can verify that the circulatory system diseases were frequent in 48.1% of the patients.This variable includes arterial hypertension, heart attack and heart failure, among others.The chronic non-communicable diseases, when neglected, favor the occurrence of some disabilities that lead to prolonged immobility and consequent risk of PI development, especially if the care with skin and the exposure to moisture is inadequate.Arterial hypertension is a silent disease, even when diagnosed and treated effectively by the Brazilian public service, and one of the difficulties of health teams is adherence to treatment.
With regard to bedtime, 81.5% of the patients were in this condition in up to 30 days.Prolonged immobility is the main risk factor for pressure injury, due to the fact that the patient's stay in the same position for a long period of time can lead to tissue death and to the occurrence of PI. [4].The majority of the patients also presented a bedtime of less than one month, but with a high PI indicator, which leads to the conclusion that the preventive measures were not effective.Concerning to feeding conditions, 40.8% of the patients presented regular condition, followed by 29.6% in bad conditions.The changes in nutritional conditions constitute a risk for the development of PI, due to a reduction of the tissue metabolism.This situation can be frequent in patients hospitalized or with chronic diseases, such as cerebro-vascular accident and spinal cord injury, which impose limitations related to the autonomy in activities of daily life and compromise the functional capacity, such as oral feeding and, in some cases, the need for a gastric or enteral catheter diet, which may lead to a reduction in the patient's body mass index and changes in the skin, mainly in its protein composition, culminating in the occurrence of the PI.[17] It is important to communicate with the multiprofessional team and, in these cases, the nutrition team plays a fundamental role in the prevention of injuries.
The identification of the patient's diagnosis can help the nurse in the assessment of other parameters that may indicate risk for pressure injuries.It is important, when assessing the clinical conditions of patients, to use different sources of information as well as interpret them adequately, in order to develop a care plan based on an interprofessional assistance.[18] In relation to urinary elimination, 40.7% of the patients were incontinent (using diapers) and 88.9% of them had fecal incontinence.The physiological eliminations may favor the development of injuries such as Incontinence Associated Dermatitis, due to the constant humidity.Dermatitis and PI are very frequent in bedridden and elderly patients, due to risk factors and to the aging physiology that, in association with incontinence, contributes to increase the injury.[4] Considering the PI development time, we can observe a predominance of the uninformed category, which indicates a failure in the nursing records, in which the nurse is the professional responsible for the history, physical examination and records of nursing care data, in the patient's medical records, from admission to discharge.
The presence of PIs is considered an adverse effect and its prevention is an indicator of quality; however, there are still few clinical studies that report the incidence of pressure ulcers when comparing the magnitude of the problem.Most PIs could be avoided if professionals had more extensive knowledge about the use of risk assessment scales and about the main characteristics of the patients that are susceptible to the development of PI, as well as the use of prevention protocols.[19] In relation with the anatomical location, the sacral region was the most frequent region (77.8),followed by ischium and trochanters.The data grouping indicated that the lower limbs represent the most affected region, as well as in the research performed in a university hospital in São Paulo.Among the ulcers evaluated, 73.1% of them affected the sacral region, followed by the calcaneal region.These areas are more susceptible to PI development, due to the great pressure made by body weight for a prolonged period.[20] The most commonly used topical therapy was Essential Fatty Acid (EFA), used in gauze in the various stages of the wound, followed by collagenase, which is used as a product to promote enzymatic debridement of slough and necrosis.The use of EFA was found in a study carried out in Campo Grande, which assessed the therapeutic methods adopted in the treatment of pressure injuries and pointed out the predominance of EFA in the treatment of pressure injury.The choice of EFA for the treatment of wounds can be justified by the lack of professional knowledge of the diversity of coverings, their purposes and indications, by the lack of institutional protocols and the scarcity of investments and finan-cial resources in new technologies for the treatment of wounds.[21] When assessing the injury stage, we can verify that most PI had no records of depth (85.2%), followed by stage 2 (22.2%) and stage 4 (18.55).This result may be related to factors such as failures in communication, nursing records, monitoring and supervision of the patients.[22] There were no conditions for defining the type of affected tissue, as in situations of necrosis, slough and deep tissue injury, which makes it difficult to choose a specific treatment for each type of injury.The predominance of pressure injury in category I, followed by category II was recognized in the study.[20] It is important to observe that, among the prevention measures of PIs -besides the coverings and the procedures of dressing changes there is a recommendation for repositioning the patient in the bed, present in most of the PI prevention protocols, occurring in every two hours, and the orientation about a common support surface and mattresses with densities lower than D33.The purpose of this procedure is to reduce or eliminate surface pressure and maintain microcirculation.The preventive measures should be established by all team that monitors and assists the patient, associated with conditioning factors such as oxygenation, feeding, motor physical therapy and systematic assessment of the skin.When occurring PI, it is important to assess its depth, type of tissue and choice of covering, according to the characteristics of the wound and with proper and regular changing of the dressing.[13] It is important that health professionals be more attentive to patients with clinical conditions, very advanced age or prolonged immobility, because this study shows that this population develops PI more easily, which may be the triggering factor for early mortality.

Conclusion
We can conclude that the prevalence of PI was high, developed in a short period of time, in the group of elderly, hypertensive, diabetic men and with circulatory system diseases.The prevalence was the development of multiple PIs, located in the sacral region with scarce records regarding the stage and treatment of PI.
Due to this fact, it is necessary to implement protocols with the use of risk assessment scales and measures for prevention and treatment of PIs, in order to reduce the prevalence of this injury and the consequent additional costs, as well as the physical and mental suffering that it causes to the patient and relatives.
Furthermore, we can observe the need to improve some fundamental notes and data records, in order to enable the clinical evaluation of the patients and the implementation of prevention measures and appropriate treatment.It is necessary to deepen the studies on PIs and the prospective researches to evaluate its incidence and prevalence.
It is expected that this research can contribute to the improvement of the performance and a greater reflection of both the health professionals especially the nurse, who deals directly with the care and has the responsibility to update and apply preventive measures, thus reducing the PI occurrences -, and managers, in order to develop public policies on the quality of the clientele's treatment, offering better conditions of structure and work to the multiprofessional team.

Limitations
The limitations of this study were related to the scarcity of information, regarding the stage of the injury and the topical therapy used in the treatment, due to the failures in the nursing records.

Table 2 .
Distribution Source: Service of Medical Records in a public hospital in Teresina, state of Piauí.#: Sum greater than 100% because a patient may have more than one injury.