Nursing care missed in patients at risk of or having pressure ulcers

ABSTRACT Objective: to determine the nursing care missed as perceived by the nursing staff and its relation with the nursing care missed identified in the assessment of patients at risk of or having pressur ulcers. Method: descriptive correlation study. The participants were 161 nurses and 483 patients from a public hospital. The MISSCARE survey was used in combination with a Nursing Care Assessment Form for Patients at Risk of or having pressure ulcers. For the analysis, descriptive and inferential statistics were used. Results: the nursing staff indicated greater omission in skin care (38.5%), position change (31.1%) and the registration of risk factors for the development of pressure ulcers (33.5%). The nursing care missed identified in the assessment related to the use of pressure relief on bony prominences and drainage tubes interfering in the patient's movements (both with 58.6%) and the use of pneumatic mattresses (57.6%). Conclusion: a high percentage of nursing care missed was found according to the staff's perception. Nevertheless, the assessment of the nursing care missed was much higher. No significant relation was found between both. Therefore, it is a priority to reflect on the importance of objective patient assessments.

Although all care outcomes are relevant, this study is focused on pressure ulcers.
Pressure ulcers (PU) represent an important challenge professionals face in their care practice, mainly because they can be prevented. One of the first steps to prevent them is the use of a scale to detect the type of risk, which can be low, medium and high.
According to the results of the assessment, a relevant care plan should be elaborated to avoid or reduce the development of ulcers. Overall, immobility is considered the main predisposing factor for the development of a PU. A relation with nutrition is also assumed. It is estimated that 95% of the PU can be avoided through appropriate management of the risk factors predisposing to their development (20) .
According to WHO, the global prevalence of PU ranges between 5 and 12%, with 7% in America and no exact data for Mexico; nevertheless, in a study developed at health institutions from the 32 entities of the federation, the rate reported was 12.92% (21) . The development of PU is closely related with the nursing care provided to the patient. It is beyond doubt that, the higher the quality and continuity of preventive care for patients at risk of developing a PU, the lower the incidence rates will be (20) . It has been demonstrated that bedridden patients present at least one pressure ulcer.
Its presence was mostly related to the lack of movement, as the patients were hospitalized at intensive care and medical-surgical services. It was also demonstrated that the ulcers were caused by deficient nutrition, as well as by inappropriate management of humidity due to incontinence (22) .
Until date, few studies have measured the nursing care missed and these have focused on the nursing staff's perception, which is relevant because of the

Objectives General Objective
Determine the nursing care missed according to the nursing staff and its relation with the care missed identified in the assessment of patients at risk of or having pressure ulcers.

Specific Objectives
Identify the nursing care missed in hospitalized patients at risk of or having pressure ulcers according to the nursing staff.

Results
According to the characteristics of the nursing staff that participated in the study, women were predominant (64.6%). The main age group varied between 26 and 30 years, followed by 20 to 25 years. As regards education, 41.6% holds a Baccalaureate in Nursing, followed by 35.4% of Nursing Technicians. The largest proportion of the staff works at the Internal Medicine service (23.6%), followed by Post-surgery and Adult Intensive Care (18% and 17.4%, respectively). Concerning the length of experience at the institution, at the service and professional experience, the largest group ranged between one and five years. The night shift was predominant (41%), followed by the morning shift and pilot plan (both 19.9%).

Discussion
In this study, it was relevant to identify the care health condition, the mortality rates can increase (6,12) .

Concerning communication, the nursing staff indicates
that it is mainly influenced by the unbalanced attribution of patients, too many patients entering and leaving and the unsuitable delivery-reception of patients. That is in accordance with different sources of evidence, mentioning that it is important to improve effective communication among health staff members; communication is crucial for the continuity of patient care, mainly in processes that require appropriate patient information transfer to avoid omissions that affect the outcomes (11)(12) .
With regard to care for patients at risk of or having PU, the assessments showed that the most missed nursing care was the use of pressure relief on bony prominences, fixation of drainage tubes without interfering in the patient's movements, patient positioning with good body alignment, use of pneumatic mattresses and daily patient hygiene (5,(10)(11) . According to the findings, during the assessments, patients with PU were found, which mostly developed while in hospital.