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.

Results:

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.

Conclusion:

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.

DESCRIPTORS
Pressure Ulcer; Nursing Diagnosis; Nursing Process; Standardized Nursing Terminology; Evidence-Based Practice

Variables	N (%)
Sociodemographic characteristics
Age*	64.8 years (+/−17.3)
Male^†	76 (55)
Caucasians^†	116 (84)
Black^†	14 (10)
Married^†	64 (46)
Widower^†	33 (24)
Some elementary school^†	60 (46.5)
Retired^†	54 (39)
Catholic religion^†	88 (64)
Reasons for admission
Sepsis^†	15 (11)
Cancer^†	13 (9.4)
Pain^†	12 (9.0)
Hip and/or knee prosthesis^†	11 (8.0)
Dyspnea^†	8 (6.0)
Lowered level of consciousness^†	7 (5.1)
Urinary infection^†	6 (4.6)
Comorbidities
Systemic Arterial Hypertension (SAH)^†	82 (59.4)
Cardiovascular disease^†	65 (47)
Diabetes Mellitus (DM)^†	52 (38)
Neurological disorders^†	51 (37)
Abstinent smokers^†	41 (30)
Neoplasm^†	34 (27)
Active smoker^†	26 (19)
Kidney disease^†	24 (17.4)
Respiratory diseases^†	23 (17)
Other clinical features
Body mass index*	23.9 kg/m² (+/−5.8)
Low weight (BMI < 18.5 kg/m²)^†	21 (15.2)
Obesity (BMI > 30 kg/m²)^†	21 (15.2)
Length of hospital stay^‡	19 days (10–35.5)
PI developed during hospitalization^†	88 (64)
PI developed in the community^†	50 (36)
PI in the sacral region^†	109 (79)
PI in the heel region^†	15 (10)

	n	%
Defining characteristics
Partial thickness loss of dermis presenting as a shallow open ulcer, intact or open/ruptured blister (consistent with a stage II PI)	75	54.4
Full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed (consistent with Stage III PI)	21	15.3
Intact skin with non-blanchable redness of a localized area, usually over a bony prominence (consistent with Stage I PI)	18	13
Purple or brown localized area of discolored intact skin or blood-filled blister due to damage to underlying soft tissue from pressure and/or shear (consistent with Suspected PI of deep tissue injury)	13	9.4
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed (consistent with Unstageable PI)	6	4.3
Full-thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, often including undermining and tunneling (consistent with Stage IV PI)	5	3.6
Related factors
Pressure over bony prominence	133	96.4
Surface friction	130	94.2
Shearing forces	129	93.5
Insufficient caregiver knowledge of pressure injury prevention	102	74
Incontinence	93	67.4
Dehydration	67	49
Extremes of weight	42	30.4
Populations at risk
Extreme of age (≥60 years)	93	67.4
History of pressure injury	51	37
Associated conditions
Pharmaceutical agent (corticosteroids, non-steroidal anti-inflammatory drug, chemotherapy and radiotherapy, immunosuppressants, painkillers and anxiolytics)	136	98
Anemia	100	72.5
Physical immobilization	122	88
Decrease in tissue perfusion	92	68
Impaired circulation	83	60
Sensory perception limitations	64	46.7
Edema	56	41
Peripheral neuropathy	55	40
Decrease in serum albumin level	49	35.5
Decrease in tissue oxygenation	34	24.6
Smoking	26	19
Hyperthermia	12	8.7

Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br

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[1] Corresponding author: Cássia Teixeira dos Santos, Avenida Juca Batista, 250, 91770-000 – Porto Alegre, RS, Brazil, cassiasantos@hcpa.edu.br