Impact of Wounds in the Assistance to Basic Human Needs in Intensive Care

Results: The most judicious care provided by the multidisciplinary team (81.7%) and the establishment of bond between professionals and clients (57.7%) were found to be the main positive effects. However, negative effects were outstanding, indicated by increased hospital stay (86.5%) and feeling of anxiety (72.1%). Despite the interference of lesions, body care (86%), communication (63.3%), and religiosity/ spirituality (43.3%) needs were referred to as met.


Introduction
The provision of assistance to a person, family or community must take into consideration who the person is, what are his or her needs, values and singularities, and must address the psychosocial, spiritual and biological dimensions.This is especially important for people admitted to Intensive Care Units (ICU), where the person's critical state requires third-party care to achieve hemodynamic balance [1][2].
Soft tissue injuries, such as pressure lesions (PL), are frequent complications in such care environment.They happen because most critical customers have sensory and motor deficit, associated with iatrogenesis and besides being bed-ridden for long times, sometimes contained, all of which favors the appearance of these lesions [3,[2][3][4].
Tissue injuries cause negative physical and emotional effects, which, in turn, can generate biopsychosocial changes on clients and their families.This is due to anxiety related to the treatment and delay in the evolution of wound healing.This can lead to depression because the damage is not only physical, but a stigma resonates in interpersonal and family relationships [5,[6][7].
Given this reality, it is essential that nursing care be grounded in the Nursing Process (NP).This working method allows nursing professionals to thoroughly meet the client's needs, even those clients with limitations caused by their uniqueness [8].Following the principles and paradigms of a theoretical basis is necessary for making the NP to occur in a systematic and deliberate manner.In this context, the Theory of Basic Human Needs (BHN) stands out.This theory is organized in three areas, structured over psychobiological, psychosocial and psychospiritual needs [9].
Upon the theoretical confirmation that the customer needs transcend the biological needs, we emphasize that healthcare practices do not involve only a limited view of the pathological aspect of the person being cared, essentially, the person with skin lesions in highly complex environment.The hospital environment itself requires a judicious care.When the characteristics of the "being" with a wound are taken into account, the nursing staff prioritizes a more attentive look and seeks to overcome the obstacles imposed to fully assist the customer and promote the improvement of his or her quality of life (QOL).
Considering the presence of the lesion as at the time of providing holistic assistance will lead nursing professionals to understand the lack of multidimensional care, emphasizing its importance for the well-being of the client.Given the understanding of nursing professionals about the importance of caring for BHN, compelling and beneficial repercussions arise for the customer when skin continuity is interrupted, since the patient will be seen in a broad perspective, having his or her needs thoroughly addressed.
Based on this assumption, the following question was raised: What are the effects of soft tissue injuries on nursing care when it comes to meeting the basic human needs in the ICU context?Are basic human needs met by the nursing staff in face of soft tissue injuries in the case of customers admitted to Intensive Care Unit?
The survey had the following objectives: identifying the positive and negative effects of soft tissue injuries and scoring the basic human needs that the nursing staff can or cannot meet before the mucocutaneous lesions of customers in Intensive Care Unit.

Methods
This was a descriptive research with quantitative design carried out in three adult intensive care units (ICU) at a hospital in Recife, Pernambuco, Brazil.The hospital chosen is considered a reference in the state.Data collection took place during the month of December 2015.The study sample consisted of 104 nursing professionals, among them nurses, nursing home residents and nursing technicians of adult ICUs.
To delimit the sample, the following inclusion criteria were used: Nurses and Nursing Techni-cians who provide assistance to clients admitted to adult ICUs and who were part of the nursing professional staff of the hospital.Exclusion criteria were: nurses and nursing technicians who work in managerial activities of adult ICUs; who were absent at the place and time of data collection; who had been working in adult ICU for less than three months.
The tool for data collection was a structured questionnaire built by researchers from Horta Theory which deals with the BHN.Questions used in interviews were: In your opinion, do mucocutaneous lesions interfere with meeting the Basic Human Needs of customers in Intensive Care Units?What are the implications of the injuries that you regard as negative and positive?Which needs you can meet?Which you cannot meet?
The research was established according to the following steps: initially, a visit to the institution was scheduled by the undergraduate researcher student in order to present the research to the target audience and give information about the relevance and goals of the study.The reason to collect data was explained, as well as how the questionnaire would be applied.Subsequently, the questionnaire was applied.Some participants responded the questionnaire during their working hours in a reserved place, according to their availability; while others chose to remain with the instrument for longer.In the last case, the deadline for delivering the questionnaire was between 24 to 36h.
For data analysis, distribution frequency of variables studied was explored.Data were entered in Excel software 2010 and transported to International Business Machines (IBM) Statistical Package for Social Sciences (SPSS) version 22.0, which made it possible to calculate the descriptive measures of absolute frequency (f) and percentages (%).
Responses of nursing technicians and nurses were investigated separately, but showed similar results when compared to their concomitant analysis, and thus are exposed in a synthesized way, in a single analysis, described in Tables and Figures. In
In the psychobiological needs, the main positive impact of the wounds was represented by more judicious care from the multidisciplinary team, with 85 (81.7%) citations.As for psychosocial needs, the establishment and deepening of the professionalclient relationship was present in 60 (57.7%) citations.It was considered that the stronger bond directly reflected in psychospiritual effects of increasing hope in recovery 72 (69.2%).This data can be viewed in the Figure 1 that follows: Negative effects of greater impact in meeting BHN were longer hospitalization and increased susceptibility to infection, both with the same percentage of 90 (86.5%) citations.As regards the psychosocial aspect, "difficulty of emotional stability" and "difficulty in accepting body image" stood out, both with 58 (55.8%) citations.Table 1 highlights these effects.Regarding physiological needs, the nursing staff states that can meet them through body care 86 (86%).The psychosocial need met that was highlighted was communication 63 (66.3%).Study participants said they meet the need for "religion/ spirituality" with a predominance of (43.3%) citations, as shown in Table 2. Regarding the failure to meet the BHN, in the psychobiological level, physical integrity was the major need that was not met, 41 (39.4%).In the psychosocial needs, a match was observed, both considered met, namely: emotional security 38 (36.5%) and communication 20 (19.2%).The greater emphasis on psycho-spiritual needs was "anxiety" and "fear of death", represented, each one, by 25 (21.2%)citations, as exposed in the Figure 2.

Discussion
Judicious care of the injury often requires a multidisciplinary approach and new technologies.This is especially the case of more complex injuries whose treatment involves the harmonious and integrated work of surgical and orthopedic teams, Hospital Infection Control Commission (HICC) and support from other areas, including psychology, nutrition and specialized nursing stomatherapy.The contribution of different professional areas with experience in the subject helps reducing prolonged hospitalizations due to wounds [12].
Nursing professionals interact more intensely with clients and establish bonds with them, because these professionals spend more time providing care.The formation of bonds leads the team towards a humanized care, where the customer is encouraged to fight the disease [13][14].Stronger bond is considered to have a therapeutic effect.It increases the confidence of customers in professionals, what has a positive impact on their treatment.This makes the patient more participatory, collaborative and leads the patient from a passive to an active attitude in the healing process [14].
Given the above, co-dependency of social and spiritual repercussions and the reaffirmation of the person being cared as a unique and indivisible individual is noticeable.This statement instigates the nursing staff to consider holistic strategies and to recognize the essence of what is seen in the critical environment, since prioritizing the stabilization of physiological phenomena can lead to devaluation of the human being.Probably, the answers of those who do not consider that there are effects (21.2%) can be influenced by a technical and mechanistic view, restricted to the biological field.
The emergence of cutaneous injuries in critical clients requires more time to resolution.The defense mechanisms and remedial actions are weakened by the clinical situation in which the person is, as well as by the use of vast array of therapies for stabilization.All of this leads to increased hospital stay [2].The injury is a gateway to microorganisms that can cause major infections, initially restricted to the wound site, and ultimately evolving to a systemic problem [15].Research conducted in Pernambuco on the characteristics of ICU infections reveals increased hospital stay of patients when infections are present [6].Thus, it is evident that lesions directly and indirectly contribute to increased hospital stay, interfering with the customer therapeutic needs.
The influence of wounds in psychological aspects of customers is evident.Patients report anxiety, sadness and discouragement, even depression.This shows that emotional distress is caused by the ICU, which instigates and strengthens feelings of negativity [17][18]7].When these feeling are associated with the presence of wounds, major effects on the customer coping ability are seen, once weakened by the peculiarities of this sector.
The presence of odor and exudate from the wound is an aggravating for body acceptance [19].People with wounds claim experiencing a grieving process with their own bodies.This situation requires an adjustment to a new physical image that they refuse to accept.Thus, the feeling of denial is constant in their lives.In that sense, the nursing staff can minimize this feeling by performing personal hygiene and dressing change before visits, providing a sense of well-being to the client.
Clients admitted to ICUs are generally permeated by fear and anxiety related to death and to the dying process and the uncertainty of the future and of their health [20,17].Associated with this, clients in this sector are frightened by the hectic routine and the fact of witnessing even more severe cases in the surrounding beds, as well as noise pollution which also cause anxiety [14].It is believed that the visual interference of the lesion generates difficulty in accepting the body image and emotionally destabilizes the client.
In these circumstances, injuries bring harm to the client's psycho-spiritual needs.The presence of in-juries is seen by them as an aggravating factor to their emotional state.It is, thus, the nursing staff responsibility to try to relieve the suffering and distress of these customers.
This result instigates a reflection on the improvement of the care and on the practice of humanized care.The latest can help the customer to avoid seeing the intensive care unit as a sector related to death.A study on the perception of critical customers after discharge revealed that they verbalized positive feelings about their stay in intensive care and did not see it as frightening environment [21].
The change of perception was caused by increased dedication and attention, feelings of affection and emotional support offered by professionals.It was emphasized that for more necessary that hard technologies may be, humanizing behaviors and appreciation of the customer as a human being endowed with feelings is essential to recovery.
Incorporating the perception of care between people, and not only the perception of the professional toward the pathology, can cause positive changes in intensive care environments, especially when it concerns psycho/socio/spiritual effects [21].
Soft tissue injuries cause significant interference to meet the Basic Human Needs.However, this does not mean they cannot be met.Nursing professionals say that body care provides comfort to the customer, and thus it is the staff's responsibility to provide this care.
Despite the interrupted skin integrity, body care must be performed.This includes hygiene, change of position, adjacent skin hydration with barrier creams, use of pressure relievers in areas of bony prominences, and keeping the skin clean and dry without fecal and urine waste.All of these are measures to prevent the appearance of new lesions, keeping thus the partial physical integrity, giving attention to the rest of the skin that is healthy [22][23].
Communication can be used as a therapeutic tool as it calms down customers, address their fears about the procedures and about their clinical condition, by making them understand what is happening [24].By establishing communication and offering emotional support, greater comfort is promoted [22].
To establish non-verbal communication, paralinguistic signal techniques may be used.These involve the sounds that are not produced by the oral/ spoken/written language; kinesis, which constitutes body language; proxemic language that addresses the physical distance established in interpersonal relations, and finally, language of touch [25].
Regardless of the state of complexity in which the customer is, comprehensive care can be provided, including the biological, psychological and sociocultural fields, in addition to the family context [26].For this, nursing professionals should provide alternatives to stimulate sensitivity and the development of the ability of a more humane relationship with the customer and the opportunity to meet the psychosocial needs [27].
Customers religiosity and spirituality are linked to their psychological well-being and raise feelings of hope and better prospects for the future [28,5].In this context, despite Table 1 shows a greater need for practicing religious activities, it is observed that respondents manage to meet the spiritual need of customers.Certainly this may be related to the approximation of the dyad and increased professionalclient relationship, which possibly favor the emotional and spiritual comfort to the client.
Basic human needs are not met in the same manner by all professionals.There are factors that affect the attitudes and practices of these professionals, as described in Table 2 and Figure 2.
The very existence of the injury is the rupture of skin integrity.By this statement, it is observed that there are different perceptions about the care of this need; ie, professionals can verbalize that they fail to meet the client's health need due to the very existence of the injury, or can confirm they meet such need as they provide care for the body surface that is still intact and by focusing efforts in wound healing [29,13].The ability to meet the need for skin integrity of the service will depend on the perception of each professional, which explains the results found in this study.
To meet the need for "communication", intrinsic characteristics that may help or not with the difficulty with this are necessary for professionals.The clinical status of the client can be sometimes regarded as an obstacle for verbal communication caused by the presence of endotracheal and comatose tube [30].Another factor that can make it difficult to meet the communication need, and consequently, emotional support, is based on the thought that many professionals have, that communication is unnecessary because many ICU customers are unconscious or disoriented.This results in lack of attention to their emotional aspect [31].
The cited psychosocial needs are similar to the psychobiological, regarding the duality of perceptions.Given that injuries cause negative repercussions, especially in the difficulty of emotional stabilization and because the care of these categories are directly related to intrinsic characteristics and care habits of the nursing team, the ability to meet them, again, depend on the uniqueness of each professional and on their theoretical knowledge based on psychobiological needs of customers [32][33].
The gap between the professional and the customer affects the quality of care.Thus, the need for improvement to promote the relationship between the hard and soft technologies is emphasized.These include establishing humanizing behaviors, in order to assist clients as unique beings with feelings and desires, even when they cannot be verbalized.This would result in a nursing practice dedicated to the fullness of assistance [31].
Faced with the failure to meet the need for emotional security, spiritual afflictions will hardly be met by some nurses.The establishment of a bond with the customer increases the risk of professionals who witness the suffering to feel the suffering them-selves.This point of view motivates professionals to keep distant, seeking to avoid emotional involvement, because the ICU environment also causes instability and emotional distress to these professionals [27].
Upon such evidence, it is apparent that meeting the psycho-spiritual needs is related to resilient attitudes of the nursing team.Soft tissue injuries cause more significant interference in the biological domain.However, the subjective and spiritual aspects of customers are more difficult to meet.This is caused by particular limitations of professionals, or arises from the unviability of wounds and the unfavorable conditions arising from the high load labor.

Conclusions
It was found that the presence of wounds positively contributes in the judicious care of the team, favoring close relationship and establishing bonds between professionals and clients.Attentive care motivates the customer to fight the disease and awakens the sense of hope fueled by faith, the belief in a higher power that promotes healing.Increased professional dedication to lesion healing entails the enhancement of the customer self-esteem.Thus, we see the close relationship between social and spiritual aspects in which the care for one has an effect on the balance of the other.
In contrast, biologically, cutaneous lesions increase the length of hospital stay, due to the worsening state of the client, reflecting on emotional instability.This, in turn, can cause depression and spiritual distress, usually related to the demotivation of curability.Psychobiological effects are more difficult to address, as they represent an intrinsic factor.In such cases, the team's efforts are focused on physiological stabilization.However, this does not prevent a humanized approach.
The care of some needs over others is related to different perceptions and caring attitudes adopted by professionals.This happens because these needs allow distinct perceptions.They set conditions on the ability to meet the need based on the conceptions and characteristics of each professional associated with the fragility of knowledge about bio/ psycho/socio/spiritual aspects and strategies that will help addressing these needs.
In this context, the present study is relevant as it identifies the interference of soft tissue lesions, as well as their positive and negative impacts, establishing itself as an important tool for the academy and for the healthcare community.This will help to qualify the assistance regarding the basic human needs of customers with soft tissue injuries, indirectly contributing to the quality of life of society.New studies are needed to confront the views of patients and caregivers, allowing the realization of plans geared to meet the needs identified by customers and promoting the comprehensiveness of care.
It is imperative to emphasize the lack of research addressing the subjectivity of customers with soft tissue injuries in the view of nursing professionals in highly complex environments.This is especially true in the case of publications covering the theory of basic human needs related to this issue.Another limitation is due to non-cooperation of some professionals to answer the instrument, what set an obstacle to the real knowledge of the needs met, especially the psychosocial and spiritual needs.
This aspect is of great importance, since it is from the observation of routine and daily practice that gaps are identified for improvement.Evidence based observations by welfare professionals are necessary for development of new care plans that may improve healthcare.International Archives of Medicine is an open access journal publishing articles encompassing all aspects of medical science and clinical practice.IAM is considered a megajournal with independent sections on all areas of medicine.IAM is a really international journal with authors and board members from all around the world.The journal is widely indexed and classified Q2 in category Medicine.

Figure 1 :
Figure 1: Positive effects of wounds when it comes to meeting Basic Human Needs in Intensive Care Unit.Recife/PE, Brazil.

Figure 2 :
Figure 2: Basic Human Needs not met by the nursing staff in patients with wounds in Intensive Care Units, Recife/PE, Brazil.

Table 1 .
Positive effects of wounds when it comes to meeting Basic Human Needs in Intensive Care Unit.Recife/PE, Brasil.Source: Research data, 2016.

Table 2 .
Basic Human Needs met by the nursing staff in patients with wounds in Intensive Care Units, Recife/PE, Brazil.