HEALTH PROMOTION AND PREVENTION OF PRESSURE INJURY: EXPECTATIONS OF PRIMARY HEALTH CARE NURSES¹

ABSTRACT

Objective:

to present the applicability of the Braden Scale in the perception of primary care nurses, and to identify preventive measures and health promotion in order to avoid the development of pressure injury.

Method:

convergent care research carried out in a health district in the South of Brazil, with 20 nurses. The data collection took place in July 2014, through an interview and practical educational in the form of a thematic workshop entitled “Say no to pressure injury, prevention is the best care”. The analysis occurred through the phases of apprehension, synthesis, theorization and transference.

Results:

the educational practice resulted in two categories: Perceptions and expectations regarding the use of the Braden Scale in primary care, which is revealed as an important tool in the recognition of vulnerable people; and Reveal health promotion practices and prevention measures to avoid pressure injuries, with goals aimed at targeting adequate care in the quest to improve the quality of life.

Conclusion:

it is concluded that adequate evaluation, care plans that can prevent pressure injury, as well as practices that promote health, are characterized as creative possibilities versus challenges, in the inclusion of a new paradigm in primary care.

DESCRIPTORS:
Nursing; Pressure ulcer; Health promotion; Primary health care; Prevention of diseases

RESUMO

Objetivo:

apresentar a aplicabilidade da Escala de Braden na percepção dos enfermeiros da atenção primária, e identificar as medidas de prevenção, e promoção da saúde de modo evitar o desenvolvimento da lesão por pressão.

Método:

pesquisa Convergente assistencial, realizada num distrito sanitário do Sul do Brasil, com 20 enfermeiros. A coleta de dados ocorreu em julho de 2014, através de entrevista e de uma prática educativa na forma de oficina temática intitulada “Diga não à lesão por pressão, prevenir é o melhor cuidado”. A análise foi através da fase de apreensão, síntese, teorização e transferência.

Resultados:

da prática educativa culminaram duas categorias: Percepções e expectativas quanto ao uso da Escala de Braden na atenção primária, sendo esta revelada como uma importante ferramenta no reconhecimento das pessoas vulneráveis; e Desvelar as práticas de promoção da saúde e medidas de prevenção para evitar a lesão por pressão, tendo esta as aspirações voltadas a um adequado direcionamento dos cuidados na busca por melhorar a qualidade de vida.

Conclusão:

conclui-se que uma avaliação adequada, um plano de cuidados que possa prevenir a lesão por pressão, assim como práticas que promovam saúde, configuram-se como possibilidades criativas versus desafios, na inclusão de um novo paradigma na atenção primária.

DESCRITORES:
Enfermagem; Úlcera por pressão; Promoção da saúde; Atenção primária à saúde; Prevenção de doenças

RESUMEN

Objetivo:

presentar la aplicabilidad de la Escala de Braden en la percepción de los enfermeros de la atención primaria e identificar las medidas de prevención y promoción de la salud para evitar el desarrollo de la lesión por presión.

Método:

investigación convergente asistencial realizada con 20 enfermeros en un distrito sanitario del Sur del Brasil. La obtención de datos se realizó en Julio del 2014 a través de una entrevista y una práctica educativa en forma de taller temático titulado “Diga no a la lesión por presión, prevenir es el mejor cuidado”. El análisis se llevó a cabo a través de la fase de aprehensión, síntesis, teorización y transferencia.

Resultados:

a partir de la práctica educativa se llegó a dos categorías: Percepciones y expectativas sobre el uso de la Escala de Braden, en la atención primaria, rebelándose como una importante herramienta en el reconocimiento de las personas vulnerables. Desvelar las prácticas de promoción de la salud y medidas de prevención para evitar la lesión por presión, teniendo las aspiraciones para un direccionamiento adecuado de los cuidados, en la búsqueda para mejorar la calidad de vida.

Conclusión:

se concluye que una evaluación adecuada, un plan de cuidados que pueda prevenir la lesión por presión, así como las prácticas que promuevan la salud, se configuran como posibilidades creativas versus desafíos en la inclusión de un nuevo paradigma en la atención primaria.

DESCRIPTORES:
Enfermería; Úlcera por presión; Promoción de la salud; Atención primaria para la salud; Prevención de enfermedades

INTRODUCTION

Nursing is a science whose objective is to care. In this perspective preventive approaches, as well as health promotion, should guide the practice of care in order to lower pressure injury prevalence.

Pressure injuries, unlike other skin changes, have been sources of concern as it represents a public health problem, leading to physical and emotional disorders which influences morbidity and mortality.¹

Epidemiological studies differ in their methodologies, which leads to a large variation in the incidence rate and prevalence. However, international studies have an incidence ranging from 4.5% to 25.2% (United Kingdom), and a prevalence of 2.9% to 8.34% (Spain), 14.8% (England) and 19.1% (USA) in home care.^2-5

As regards to Brazil, there are few studies on the prevalence and incidence of the disease, however, with regard to home care, there are studies which showed a 41.2% to 59% risk for the development of pressure injury and a prevalence of between 8% and 23%, this is a cause for concern as it is something which can be prevented in up to 95% of cases, as determined by the Rio de Janeiro Declaration on the Prevention of Pressure Injury.^6-10

It is known that care for people with pressure injuries should occur in high and medium complexity health services, as well as Primary Health Care (phc), under the care of the Family Health Team (ESF), which refers to the establishment of guidelines which guide the practice of prevention, with the need to move towards health promotion actions.

Health promotion, according to the National Health Promotion Policy (PNPS), is fundamental in improving the quality of life, and has been standing out as a health strategy in which the community assumes itself as an agent of its recovery.^11-12 Conceptually, health promotion is related to the condition of life, strengthening of autonomy and reinforcement of public policies, and prevention is linked to the reduction of the risk of diseases or specific illnesses.¹³

Thus, in this search for the reduction of the disease, the nurse as a member of the ESF plays a fundamental role in assisting in better care practices, enabling people and their families to become protagonists in the process of self-care.

However, in order to avoid pressure injuries, in addition to specific measures, the nurse needs to systematically evaluate using instruments available in the international domain, such as the Braden Predictive Scale, which has presented high sensitivity and specificity rates in Brazil.^6,14 The Braden Scale aims to identify the development of pressure injury in vulnerable individuals. It is composed of six subscales which assess sensory perception, skin moisture, nutritional status, degree of activity and mobility, and exposure to friction and shear. The sum of the scores results in values between six and 23, and the lower the score, the greater the risk developing a pressure injury.^15-17

The Braden Scale is an important step in nursing care as when it is used correctly it can help to prevent the development of the pressure injury, however, the lack of systematic evaluation, as well as a care plan aimed at preventing the injury and promoting the health of people at home, can be seen as a gap in the knowledge in the area of PHC.

Faced with these problems and concerns, the following questions arise: how do nurses evaluate the Braden Predictive Scale in their daily practice? What are the preventive measures and health promotion practices adopted to prevent the development of pressure injury in the context of PHC?

This study aims to present the applicability of the Braden Scale in the perception of PHC nurses, and to identify the preventive and health promotion measures adopted which are used to avoid the development of pressure injuries and positively impact the quality of life of people.

METHOD

A qualitative, descriptive study that used the methodological precepts of the Convergent Care Survey (PCA). This methodology unites thinking and taking action, resulting in critical and reflective know-how. It allows observing and researching, and its main characteristic is the direct and intentional articulation with the caring and/or educative practice in the studied context and, at the same time produced data for the study.

The study was carried out in a Health District (DS) of a municipality in the South of Brazil, in July 2014. At that time, the DS had 30 ESF, with one nurse per team, distributed in 12 Health Centers, which motivated choosing this DS. Twenty nurses participated in all stages of the research. The inclusion of the participants included; being a nurse in the ESF, due to the connection with the community, and to be in professional practice during the period of data collection, and those who exclusively worked in the administrative area, such as the coordinator were excluded from the study. Data collection took place in the nurse’s meeting room in the same institution.

In respect to the methodology, the PCA was conducted in two stages, initially with the interview which consisted of two open questions which were asked to each one of the participants, in order to clarify the objective of this research.¹⁹ The first question asked how the participants identified the people who were at risk of developing pressure injury in their work context, thus revealing knowledge about the Braden Scale, and the second question sought to know, through risk assessment, what practices were implemented to avoid pressure injuries. For this corresponding interview, a one hour time limit was given for the participants to respond, being that they used 30 minutes of the one hour time limit, and had to think of elements to help the planning of the subsequent stage. The sociodemographic profile of the participants was also obtained.

The second step was through educational activities, through the thematic workshop, entitled “Say no to pressure injuries. Prevention is the best care”. Prioritizing the acts of thinking, dialoging and constructing, the thematic workshop was planned based on the analysis of interview information, whose responses expressed the participants’ knowledge regarding pressure injury.

The workshop took place in a single day, lasting approximately four hours, and consisted of three stages:¹⁸ 1) welcoming the participants and the preparation of the environment; 2) performance of the central activity with constructions, reflections and discussions; And 3) clarifications, other contributions and finalization.

In order to motivate participation and enrich the debate, text reading techniques, descriptive content with the help of PowerPoint, and group reflections on The National Policy on Health Promotion and International recommendations of the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (EPUAP/NPUAP).

The activities were performed in groups called “G1, G2, G3, G4 and G5”, where the participants could freely choose the organization of their members, which allowed greater mixing among the groups, increasing knowledge exchange.

The data of the study that emerged from the discussions and reflections and the collective construction of the measures of prevention of the pressure injury, based on the Braden Predictive Scale, in addition to the practices of health promotion, were recorded and later transcribed, and consisted of the involved theoretical and methodological questions.

The analysis began with the apprehension phase which was developed by the selection of the keywords that appeared repeatedly. Afterwards, the interpretation took place with the synthesis stages, which gave rise to the categories and theorizing, articulating the information categorized with the literature and the data transfer.¹⁵

The activities only began after the Term of Free and Informed Consent was signed ensuring that the required ethical standards were upheld. Anonymity was ensured by participants being identified by groups and represented by letters. It should be highlighted that this research was approved by the Research Ethics Committee of the Federal University of Santa Catarina under no. CAAE 3209514.3.0000.0121, and opinion no. 711,385, on July 7, 2014, and that all the ethical precepts of the directives and norms regulating research involving human beings have been observed, Resolution 466/12 of the National Health Council.

RESULTS

After analyzing and organization by affinity, the data from this study resulted in two categories: Perceptions and expectations regarding the use of the Braden Scale in PHC; and Revealing health promotion practices and prevention measures to avoid pressure injury. These categories support the design of this study in the acquisition and improvement of knowledge regarding the subject of pressure injuries, contributing to health professionals’ understanding of how essential safe and quality nursing care management is.

Initially, in order to situate the reader, the sociodemographic characterization of the participants will be presented.

Twenty health professionals participated in the study. The age range varied from 21 to 50 years of age, consisting of 17 women, two men and one did not respond. Regarding marital status, six were married, seven were single, two were in a civil union, and one did not respond. The duration of work experience post gradation ranged from one year to 30 years, with most professionals having between three and 15 years of experience. Of these participants. 19 responded that they had completed a specialization, 12 were specialized in Family Health, and only one did not mention a postgraduate course. The duration of APS ranged from six months to 20 years, with the majority having between two and 20 years of experience in PHC. The time spent in SMS ranged from six months to 20 years, and 19 have a statutory work contract. Only one did not respond.

Perceptions and expectations regarding the use of the Braden Scale in APS

Regarding the applicability of the Braden Scale in the context of nurses’ work, the results presented here, mainly represented acceptability in the use of the PHC scale.

We found it quiet to use. Even very interesting (G1-O).

It is a good scale, especially for the bedridden [...] . You have this ease of counting. I think it’s very quiet, [...] . Nice. I thought it was good. Really cool (G3-F).

With the use of the Braden Scale, participants expressed the possibility of alternatives to other clinical parameters, as well as a using it as a guide for a more consistent, fast and safe assessment for both nursing and FHS: For example, sometimes we have this more empirical outlook (G1-A).

So, there is another source [...] which we can also use to analyze (G2-D).

Even by the score itself, we can guide our ... care (G3-G).

You go, pay a visit, or evaluate a patient quickly (G3-F).

This is not just the nursing itself. We go with other professionals, and we can take this as a parameter, even as a consensus for evaluation (G3-F).

The perception that using the Braden Scale provides more accuracy in the nursing diagnosis and focuses on priorities, with the suggestion to focus on the lower performing subscales can be seen in the following statements.

So, I think I can visualize the situation that I am evaluating better (G3-F).

We can make a nursing diagnosis using the criteria, characteristics, in inverted commas, right there and then and evaluate the case better (G3-F).

The sub scale related to the disabled patient could be focused on more, it could be worked on more [...] (G5-J).

Interesting. The patient is at low risk of developing a pressure injury, but there are still things that need to be worked out [...] (G4-H).

Participants, while most of them positively evaluated the applicability of the Braden Scale to practice, also expressed anxieties and difficulties in interpreting the subscales.

I have doubts occur when using it [...] . It is not as easy to use in practice as it is here (laughs) (G4-H).

I think activity and mobility is confusing. Because at first they seem the same thing (G1-B).

The predictive scale for pressure injuries is considered an important tool in the recognition of vulnerable individuals. However, in order to avoid the occurrence of such injuries, it should not be used just for evaluation, but follow an appropriate direction of care, subject to the next category.

Revealing preventive measures and health promotion practices to avoid pressure injury

Care related to prevention and health promotion actions originating from the collective construction of the participants emerged from common aspects which were identified and presented in table 1.

Table 1
Distribution of health promotion practices and measures to prevent pressure injury in the context of PHC. Florianópolis, 2014

Prevention measures

Health Promotion Practices

→ Examine the skin daily in detail by inspection and palpation → While performing patient hygiene use this time as an opportunity to examine the skin → Take care of the temperature of the water during the bath. Prevent it from being too hot. → Keep skin free of body fluids by cleaning with dampened cotton or a wipe that has lanolin. → Use moisturizers and emollients on the skin. → Provide adequate water intake and balanced nutritional intake (high in protein). → Use skin protection guards. → Avoid applying high-alcohol products to the skin. → Avoid massages on bony prominences. → Use elasticated cotton sheets on the bed. → Use external urinary devices. → Change incontinence pads whenever necessary. → Use appropriate support surfaces (pressure care mattresses, pillows, cushions, foam roller) → Position pressure cushions above or below boney prominences, avoiding pressure at the site. → Change position or turn patient at least every two hours. → Keep the headboard at a maximum angle of 30º (decreases shearing). → Change sitting position every 15 minutes or tilt the body to one side or the other (decreasing the pressure of the person's gluteal region). → Attempt to maintain pressure mattresses clean and free from dust mite accumulation, and bacteria. → Avoid the use of heel pads, cushions, or air bubbles or water-wheel type (do not push on prominence, but use on the adjacent area).

→ Encourage self-care. → provide guidance on health education to the patient, family member and caregiver, involve the family in care. → include and encourage family and community performance as action subject → consider family habits using this in favor of building more appropriate ones. → consider social, economic and cultural aspects of the patient, family and caregivers. → adjust the care based on the socioeconomic conditions of the family, encourage healthy food, adequate preparation, and paying attention to access to food. → consider the family's difficulties in caring for nutrition (especially the use of tube feeding). → assessing the person's physical condition (eg, no teeth, swallowing may become inadequate, difficulty to digest food, poor nutrition, or bedridden, or unable to even move an arm). → evaluate who the caregiver is, who is doing the care. Be aware of who is taking care of the patient (the daily jobs, there is usually an accumulation of functions). → Orientate the caregiver. Take care of those who are taking care of small tips to also not get injured, do not bring harm to themselves (which makes big difference). → seek the co-responsibility of those involved. → promote emotional support for family members and patients. → stimulate interdisciplinary actions and involve other professionals: nutritionist, psychologist, geriatrician, physical educator, physiotherapists. → stimulate the evaluation of the multi-professional team. → consider that when the family understands the importance of all the prevention actions, it will do them, and they also end up doing the promotion as well. → admit that prevention and promotion often go hand in hand.

In this category which addresses the aspirations to avoid pressure injury and to improve the quality of life of people vulnerable to pressure injuries, prevention measures regarding skin were suggested including inspection, cleaning, hydration and protection with the use of dermoprotectants. The reduction of skin exposure to moisture was considered as well as measures that should be avoided such as the use of products that alter the Ph. of the skin, the use of gloves with water on bony prominences and vigorous massages. Adequate nutritional intake and planned positioning and frequent repositioning, including those using a wheelchair, were also suggested.

In preventive actions, care was also focused on the environment, clean stretched out bedding, pressure redistribution devices (cushions, pillows), as well as specific mattress and the proper maintenance of such mattresses.

Regarding health promotion, the results indicated that participants, although in a health-care-illness scenario, were challenged to go beyond the walls of the biologistic concept and, considering the inclusion of self-care, considered the active participation of people vulnerable to Pressure injuries, as well as relatives, caregivers and the community, as being co-responsible and, above all, protagonists of their process of living healthy.

The results showed relevance to emotional support, health education with orientations based on habits, socioeconomic and cultural aspects, valuing potentialities and depreciating weaknesses, for the reorientation of health practices. They also emphasize the importance of healthy eating and admit possible physical restraints of the person susceptible to pressure injury, as well as the limitations of the family as well as access to food and related care.

The caregiver was also mentioned, who are worthy of care according to the participants. In addition, the multi-professional team and interdisciplinary actions were highlighted as well as the inclusion of prevention guidelines accepted by those involved, which results in health promotion, where they go hand in hand in the same direction.

DISCUSSION

Regarding the perceptions and expectations of the Braden Scale in PHC, nurses considered the Braden Scale as a useful tool which can guide clinical practice, ratified by studies^20-21 that conclude that the use of assessment tools are valuable tools which predict the onset of the pressure injuries including in the home environment in which the Braden Scale proved to be effective. Corroborating this finding, the identification of weak points can guide planning for prevention with a focus directed to individualized needs, and may improve health promotion actions in particular.²²

With regard to the systematization of care, a study²³ which cross examined nursing care for patients at risk of pressure injury and the interventions from the Nursing Interventions Classification (NIC) based on the Braden Scale showed similarities by demonstrating an effective relationship between the scale and Nursing diagnoses, a result which is also considered in this research.

The use of this Scale can become a great ally to the nurse which can increase the quality of the service provided to the person with a pressure injury, as it allows to know the profile of the patient and directs the systematization of care. In order for the use of the scale to become effective, the professional must be properly trained, ensuring that there are no limiting situations based on the interpretations of the evaluators’ scores.¹⁶ For an adequate evaluation, in addition to its structured approach, as in the case of the Braden Scale, clinical judgment is essential, and where one does not replace the other.^24-25

Thus, it is fundamental that nurses develop skills in order to use this instrument, the lack of skills is a weakness which is pointed out in part of this research, ratified by studies^26-28 which highlight the need of nurses, who still do not routinely use technology in the evaluation and prevention of pressure injuries, must become familiar with such instruments and help reduce the negative repercussions of this challenging problem.

The category “Revealing health promotion practices and prevention measures to avoid pressure injury” initially points out that the main objective of collective construction of actions, whether to prevent or promote, permeates the quest for people’s quality of life.

As a prevention, the importance of skin care is found in studies^24,29 which include the use of creams, management of incontinence with the use of barrier products, frequent examination, as well as actions that should be avoided such as massages, the use of ring shaped devices and/or gloves with water.

Regarding adequate nutrition, the incidence of PUs is directly related to malnutrition, with nutritional intake being part of the preventive intervention.^17,29 On the other hand, when changes in nutrition change, together with problems of friction and/or shearing and alteration of sensory perception and humidity, the risk of pressure injuries is increased

Moreover, with regard to wheelchair users who are susceptible to developing pressure injuries, repositioning and surface supports are considered to be useful methods of preventing pressure injuries,^25,31 which is also a finding considered in this research.

In order to improve care and the quality of life of people nurses need adequate training to acquire skills for action planning, evaluation, prevention and treatment, as well as skills to educate the people and their families.³²

Therefore, it is important to emphasize the importance of strategic actions that aim to develop personal skills which stimulate self-care by inserting the individual and his family into their own health context.³³ The recognition of this was also pointed out by the participants, who stated the inclusion of the family and the communities as protagonists of care, in a dialogical and autonomous relationship.

Health education as a care practice is essential for the achievement of health promotion, and one is not limited to the other.³⁴ It is identified that both are essential for nursing care directed at people with pressure injuries and their relatives. The professionals have knowledge regarding the actions of promotion and also how to prevent the aggravation, and when the educational practices are performed their technical and scientific foundations are improved.

Healthy eating is also brought up as a health promotion practice, and also as a primary recommendation in the prevention of pressure injury in vulnerable people.^11,24 Although essential, difficulties at achieving a healthy diet have been pointed out , such as clinical restrictions, and even socioeconomic issues, which makes the access to food necessary for the person susceptible to developing the pressure injury and their families even more difficult.³⁵ Nurses play a fundamental role in the implementation of the health promotion policy, combining practice and knowledge to deal with the needs of users and their social determinants.

The need for a multi-professional team with interdisciplinary actions, in a collaborative partnership with several health professionals and other sectors of society is pointed out in the literature^36-38 as concepts that are related to health promotion and the organization of services with emphasis also on the intersectoriality between the worker and the three management spheres.

Understanding prevention, in an expanded concept, results in promotion. A finding of this research that concurs with studies^39-40 point to the tenuous line of these two practices, which show that the nurses conceive the idea of promotion through practice developed within the preventive vision.

Studies^27-28,41 show that responsibility for health promotion is shared among individuals, communities and institutions. However, in Brazil, promotion practices are still fragmented and focused, and there is an urgent need to level clinical care, prevention and promotion, and it is fundamental to sensitize the ESF in order to break from this traditional model of health care, with a positive impact on the individual, family and community, because then, health is not thought of as the absence of disease, but as a resource of life.

CONCLUSION

It was possible to understand the perception of PHC nurses regarding the relevance of the Braden Scale as one of the preventative measures and health promotion practices that can prevent the development of a pressure injury.

Adequate evaluation and a well-designed care plan that can prevent pressure injury, as well as health promoting practices with the involvement of the person, the family and the community, represent creative possibilities versus challenges in the insertion of a new paradigm in the PHC context.

Through dialogic process the study provided a continuous doing and undoing discourse of teaching and learning, action and reflection, favored by methodological strategies. In addition, it provided the means to assess the person likely to develop the disease using a useful instrument, as well as possible measures to prevent pressure injury and promote health in a way that positively impacts the quality of life of those involved.

It also gave rise to important reflection. It is hoped that these results will contribute to health professionals’ identification of the need to innovate care, and that more research can be done to obtain greater consistency of knowledge regarding the subject of pressure injury. Based on the results, it is perceived that one of the limits is the incorporation of these health promotion practices and prevention practices in the work process of the PHC nursing professionals, in order to reduce pressure injuries from those involved and to achieve improvements in health conditions.

Emphasis must be placed on the importance of scientific knowledge in order to broaden the understanding of care associated with good health practices, especially in the design and implementation of prevention measures focused on pressure injuries and health promotion practices, aiming to improve the quality of life, as well as to stimulate the development of new researches and to advance the area of nursing.

• 1
  Extracted from the dissertation - Pressure ulcers in the primary care context: Nurses’ reflection on the Braden Scale, presented to the Programa de Pós-graduação em Enfermagem (PEN) of the Universidade Federal de Santa Catarina (UFSC), in 2015.

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Publication Dates

• Publication in this collection
  2018

History

• Received
  02 Apr 2016
• Accepted
  09 Mar 2017