Instruments for the care of pressure injury in pediatrics and hebiatrics: an integrative review of the literature

ABSTRACT Objective: to identify existing instruments in the scientific literature about the care of pressure injuries in pediatric and hebiatric patients. Method: an integrative review that selected 32 articles from the PubMed/Medline, LILACS, Scopus and CINAHL databases using the descriptors pressure ulcer, decubitus ulcer, pediatrics, adolescent and protocols and their equivalent terms in Portuguese and Spanish. Inclusion criteria: research articles in full, in Portuguese, English or Spanish without any temporal cut-off. The descriptive analysis was adopted to categorize the instruments found into the three domains of care: evaluative, preventive and curative. Results: 25 instruments for the care of pressure injuries in pediatric and hebiatric patients were found, with an emphasis on the Braden Q Scale being the most commonly used to assess pressure injury risk, and the protocols containing pressure injury staging guidelines developed by the National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Ulcer Advisory Panel (EPUAP). Conclusion: the scientific literature has valid and reliable instruments that can be used in nursing care practice aimed at the evaluative, preventive and curative care of pressure injuries in pediatric and hebiatric patients.


Introduction
The care for hospitalized children and adolescents requires the nursing team to recognize their needs, taking into account the different stages of development (1) . To exercise this care, the use of technologies that cover the technical and scientific knowledge translated into tools, processes and materials created and used is essential (2) , systematizing the care to favor the maintenance of life, provide comfort, well-being and recovery of health.
Among these technologies, we can highlight instruments that express systematized thinking with a specific purpose, which represents a record/registry and promotes and guides the care process. They can be represented as a consultation script, a scale, a functional organization chart, a protocol, a checklist, or a questionnaire, among others (3) . They represent tools that qualify the care and reflect the care quality Indicators have been studied in seeking care quality, benefiting hospitalized patients (4) ; among these, we can highlight pressure injuries, which are part of the set of quality indicators related to nursing care processes (5) .
The term "pressure injury" has been used to replace the terminology of pressure ulcer previously used by health professionals, a change that took place in April 2016 (6) .
Although they are more frequent in the older adult and adult population, pediatric patients are also at risk of developing these injuries.
Studying pressure injuries is important, since prevention and treatment are attributed as a way to reduce patients hospital stay and thus diminish costs, prevent infections and improve patient prognosis (7) .
Data collected regarding the prevalence of pressure injuries in the United States in hospitalized patients aged 0 to 18 years showed prevalence rates of 1.4% and prevalence of hospital-acquired pressure injuries of 1.1%. Rates are even higher among patients in pediatric intensive care units (3.7%) and pediatric rehabilitation (4.6%), while the general pediatric units had a lower prevalence (0.57%) (8) . In Brazil, the prevalence of pressure injuries among children and adolescents at a hospital in Paraná was 8.06% (9) . In a pediatric intensive care unit in Ceará, seventeen children (42.5%) developed 26 pressure injuries (10) .
In this context, nursing professionals use care technologies that include knowledge justified by scientific principles and proposals of techniques, procedures and knowledge for their care practice (2) .
Based on the risk of developing pressure injuries in pediatric and hebiatric patients, the use of instruments so that specific interventions are incorporated into patient care is urgent (11) , which may characterize it as care technology. Preventing pressure injury is a nursing responsibility, whose instruments are important components for effective and efficient care (12) . It is noticeable that these instruments are increasingly present in the routine of nursing professionals, becoming indispensable care tools in pediatric and hebiatric medicine.
In view of the above, we consider it is fundamental to promote the discussion about the instruments used in the care of pressure injuries in pediatric and hebiatric patients.
Considering the importance that instruments which focus on the care of pressure injuries in this population have for nursing professionals, an integrative review was carried out with the objective to identify existing instruments in the scientific literature about the care of pressure injuries in pediatric and hebiatric patients.

Methods
This is an integrative review of literature in the field of pediatrics and hebiatrics on instruments for the care of pressure injuries. Six steps were followed for this review: identifying the theme and selecting the hypothesis or research question to elaborate the integrative review; establishing criteria for inclusion and exclusion of studies/sampling or search in the literature; defining the information to be extracted from the selected studies/categorization of the studies; evaluating the studies included in the integrative review; interpreting the results; and presenting a knowledge review/synthesis (13) .
The searches were conducted from October to December 2016, guided by the following question: which instruments exist in the scientific literature for the care of pressure injuries in pediatric and hebiatric patients?
The following databases were used: National classification, which considers those up to nine years of age as children, and those in the chronological limit between 10 and 19 years as adolescents (14) .
The inclusion criteria were: answering the guiding question; constituting a research article available in full in Portuguese, English or Spanish with no temporal cut-off; published in scientific journals and available electronically.
The following exclusion criteria were adopted: literature review, editorials, reviews, case reports, case studies, theoretical reflections, dissertations, theses, monographs and abstracts published in event archives. Repeated articles were also excluded, thus only maintaining the first identified version.
An instrument prepared by the authors was used in order to collect the data, in which the necessary information to answer the research question such as titles, authors, years, bases, objectives, environments, populations and instruments used were organized.
In addition to the data characterizing the studies, we sought to extract information about the type of instrument (scale, protocol, checklist, questionnaire, computerized system and form), the population and the application environment of the instruments. The study selection followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (15) , as shown in Figure 1. The articles initially selected in a consensual way (by the independent researchers) were automatically accepted. The articles selected in a discordant manner were discussed on a case-by-case basis until agreement was reached.  at preventing the onset of pressure injury; and curative care refers to the treatment of pressure injuries (16) .
No qualitative articles were selected. The quantitative articles found in the investigated databases and included in this review are presented in Table 1.

Care domains Instruments Populations Environment
Evaluative Pressure injury staging by the National Pressure Ulcer Advisory Panel (16,17,35,(37)(38)(39) Children and adolescents (one to 18 years of age) PICU * ; Department of Neurology; Pediatric hospital Preventive Care guidelines based on the American HealthCare Research and Quality (17) Children subjected to orthopedic correction Skin Care Specialist Clinic

Evaluative and Preventive
Bundle Pressure Ulcer Prevention Program (22) Children from zero to three months PICU * Curative Laser protocol to heal skin lesions (23) Adolescents over 15 years of age Spinal Cord Center (Centro da Medula Espinhal) Evaluative Pressure injury staging of the European Pressure Ulcer Advisory Panel (32,37) Children and adolescents (zero to 18 years of age)
Other scales were also found in the review,  (49) .
In addition to these scales, the Garvin Scale is based on four risk factors: mobility, sensory perception, nutrition and moisture, in which a total score is used to divide children into categories with increasingly intense interventions as the risk increases (21) .
The comparison between the Glamorgan Scale, the Braden Q Scale, and the Garvin Scale identified that the Glamorgan Scale (area of 0.912, p<0.001, 95% CI=0.873-0.946) has a greater predictive power than the Braden Q scale (area of 0.694, p<0.001, 95% CI=0.627-0.762) or the Garvin scale (area of 0.641, p=0.001, 95% CI=0.570-0.712) (21) . Nevertheless, we can point out that the Braden Q Scale is the most used in studies, possibly because it was the first to be published.
Other assessment scales were found addressing skin ruptures in neonates (Neonatal Skin Risk Assessment Scale -NSRA) (34) , in which the degree of risk perceived by the nurses is marked on a 100 mm horizontal line, anchored by word descriptors at each end such as "no risk" and "maximum risk" (Visual Analogue Scale-VAS) (31) ; and also a scale that measures the risk of skin rupture with a high level of specificity (Starkid Skin Scale) (36) .
In addition to these, the Bates-Jensen Wound Assessment Tool (BWAT) was also found, which differs from the others as it evaluates installed injuries by considering the following aspects: wound size, depth, with the total value ranging from 13 to 65 (35) . It was translated and adapted for Brazilian culture in 2015, and named the Bates-Jensen Wound Assessment Tool -Brazilian version (50) .

The Pressure Ulcer Prediction and Evaluation Tool
(PPUPET) is a scale that evaluates aspects related to mobility, activity, sensory perception, humidity, external medical devices, friction/shear, perfusion and tissue oxygenation, skin condition and nutrition (18) .
In view of the above, nurses could more accurately determine interventions for prevention and treatment of pressure injury by applying a predictive risk scale and performing a clinical evaluation, then using this data to conduct a care plan for pressure injuries (51) .  (52) . In addition, there are care guidelines based on the American Health Care Research and Quality (AHRQ), which has the mission of producing evidence to make health care safer, affordable, equitable and of higher quality (17) . There is also the Quality-improvement guideline, which is focused on reducing the rate of pressure injury in pediatric and neonatal intensive care units (40) . With a similar proposal, the Practice guideline and skin breakdown was created to direct the practice and guide the professionals of pediatric cardiac intensive care units about interventions for possible problems of skin rupture in patients (41) .
Protocols for the prevention and/or treatment of pressure injury are also part of existing instruments for such purposes. The Bundle Pressure Ulcer Prevention Program (PUPP) was evaluated to determine whether there is an association between its implementation and a significant reduction in the development of pressure injury in a pediatric intensive care unit (22) . In general, the instruments were aimed at children and adolescents; however it can be questioned whether those instruments aimed only at pediatrics could not be adapted and used for hebiatric/adolescent patients, since both groups are at risk of developing pressure injuries.
As a contribution to clinical practice, this integrative review grouped and synthesized knowledge on instruments for the care of pressure injuries in pediatrics and hebiatrics with the purpose of making evidencebased practice of health professionals feasible in the care of children and adolescents.
As a limitation we can point out the methodological data collection from the studies, considering that many did not explicitly present a description of the study type, making it difficult to identify the levels of evidence.

Conclusion
The results obtained in this review show 25 existing instruments in the literature that can be used for the care of pressure injuries in pediatric and hebiatric patients, including scales, protocols, system, forms, checklists and questionnaires. We point out the Braden Q scale was the most used instrument to assess the risk of pressure injury. With regard to protocols, we can point out adopting the guidelines for the staging of pressure injuries developed by the NPUAP and the EPUAP.
Although pressure injury is not very common in this population, the results have contributed to show that the subject has been studied and that the instruments for evaluative care have been most used to provide qualified and safe care in pediatrics and hebiatrics.
In view of the above, nurses have instruments available to evaluate, prevent and treat pressure injuries, which will assist in creating and implementing a specific care plan based on scientific evidence.
Skin care is one of many nurses' roles, however these professionals must work together with the multiprofessional team to assess, prescribe and implement preventive and curative care of pressure injuries by making use of the technologies in this process.