Cross-sectional study that aimed to compare the data reported in a system for the indication of pressure ulcer (PU) care quality, with the nursing evolution data available in the patients' medical records, and to describe the clinical profile and nursing diagnosis of those who developed PU grade 2 or higher Sample consisted of 188 patients at risk for PU in clinical and surgical units. Data were collected retrospectively from medical records and a computerized system of care indicators and statistically analyzed. Of the 188 patients, 6 (3%) were reported for pressure ulcers grade 2 or higher; however, only 19 (10%) were recorded in the nursing evolution records, thus revealing the underreporting of data. Most patients were women, older adults and patients with cerebrovascular diseases. The most frequent nursing diagnosis was risk of infection. The use of two or more research methodologies such as incident reporting data and retrospective review of patients' records makes the results trustworthy.

Cross-sectional study that aimed to identify subscales scores that evaluate the risk for pressure ulcer in the implementation of the Braden Scale, and associate them with reasons for hospitalization, comorbidities and demographic characteristics of the hospitalized adult patients. The sample consisted of 187 patients at risk for pressure ulcer with a total score ≤13 on that scale. Data were collected retrospectively in the sheets with the Braden Scale and medical records, analyzed by descriptive statistics and tests of Mann-Whitney and Spearman. The results showed majority of women and elderly with cerebral, pulmonary, cardiovascular, metabolic and cancer diseases. The scores verified by the subscales indicated bedfast patients with limited mobility and activity. The altered nutrition was also an important factor, followed by the problems of friction and/or shearing, alteration of sensory perception and moisture. These findings allow us to support the prevention qualification of pressure ulcer.DESCRIPTORS: Pressure ulcer. Nursing care. Protocols. ANÁLISE DAS SUBESCALAS DE BRADEN COMO INDICATIVOS DERISCO PARA ÚLCERA POR PRESSÃO RESUMO: Estudo transversal com objetivo de identificar a pontuação das subescalas que avaliam o risco para úlcera por pressão na aplicação da Escala de Braden e associá-las aos motivos de internação hospitalar, às comorbidades e às características demográficas de pacientes adultos hospitalizados. A amostra constou de 187 pacientes em risco para úlcera por pressão com escore total ≤13 na referida escala. Os dados foram coletados retrospectivamente em fichas com a Escala de Braden e em prontuários, analisados pela estatística descritiva e testes de Mann-Whitney e Sperman. Os resultados demonstraram maioria de mulheres, idosos, portadores de doenças cerebrovasculares, pulmonares, cardiovasculares, metabólicas e neoplásicas. Os escores verificados pelas subescalas apontaram pacientes acamados, com mobilidade e atividade limitadas. A nutrição alterada também se mostrou fator importante, seguido pelos problemas de fricção e/ou cisalhamento e alteração da percepção sensorial e umidade. Estes achados permitiram subsidiar a qualificação da prevenção da úlcera por pressão. DESCRITORES:Úlcera por pressão. Cuidados de enfermagem. Protocolos. ANÁLISIS DE LAS SUBESCALAS BRADEN COMO INDICATIVO DE RIESGO PARA LAS ÚLCERAS POR PRESIÓNRESUMEN: Estudio transversal con objetivo de identificar la puntuación de sub escalas que evalúan el riesgo para la úlcera por presión en la aplicación de la Escala de Braden, y asociarlas a los motivos de hospitalización, comorbilidades y características demográficas de pacientes adultos. La muestra fue de 187 pacientes con riesgo de úlcera por presión con un puntaje total ≤13 en la referida escala. Los datos fueron recolectados retrospectivamente en fichas que contiene la Escala de Braden y en los registros médicos, analizados por estadística descriptiva y test de Mann-Whitney y Spearman. La mayoría eran mujeres, ancianos, con enfermedades cerebrovasculares, pulmona...

This cross-sectional study characterizes patients at risk of Pressure Ulcers (PUs) and identifies their corresponding Nursing Diagnoses (NDs). The sample consisted of 219 hospitalizations of adult patients at risk for developing a PU established through the Braden Scale. Data concerning the results of the application of the Braden Scale were retrospectively collected from the patients' medical files and statistically analyzed. Most patients were elderly women hospitalized for an average of nine days, affected by cancer, cerebrovascular, lung, cardiovascular and metabolic diseases. The most frequent NDs were Risk for infection, Self-care deficit syndrome, Bathing/ hygiene self-care deficit, Impaired physical mobility, Imbalanced nutrition: less than body requirements, Ineffective breathing pattern, Impaired tissue integrity, Acute pain, Impaired urinary elimination, Impaired skin integrity, and Risk for impaired skin integrity. We conclude that most NDs are common in clinical nursing practice. Perfil clínico y diagnósticos de enfermería de pacientes en riesgo de contraer úlcera por presiónSe trata de un estudio transversal con objetivos de caracterizar a los pacientes en riesgo de contraer úlcera por presión (UP) e identificar sus diagnósticos de enfermería (DEs). La muestra consistió de 219 hospitalizaciones de pacientes adultos en riesgo de contraer UP, determinado por la Escala de Braden. Los datos fueron recolectados retrospectivamente en registros de la Escala de Braden en ficha electrónica y, analizados estadísticamente. La mayoría de los pacientes fueron mujeres, ancianos, con tiempo de internación promedio de nueve días y portadores de enfermedades cerebrovasculares, pulmonares, cardiovasculares, metabólicas y neoplásicas. Los DEs más frecuentes fueron Riesgo de infección, Síndrome de déficit en el autocuidado, Déficit en el Autocuidado: baño/higiene, Movilidad física perjudicada; Nutrición desequilibrada: menos que las necesidades corporales, Estándar respiratorio ineficaz, Integridad tisular perjudicada, Dolor agudo, Alteración en la eliminación urinaria, Integridad de la piel perjudicada, Riesgo para perjuicio de la integridad de la piel. Se concluye que estos DEs, en la mayoría, son comunes a la práctica clínica de enfermería.

Objective: to validate the content of the new nursing diagnosis, termed risk for pressure ulcer. Method: the content validation with a sample made up of 24 nurses who were specialists in skin care from six different hospitals in the South and Southeast of Brazil. Data collection took place electronically, through an instrument constructed using the SurveyMonkey program, containing a title, definition, and 19 risk factors for the nursing diagnosis. The data were analyzed using Fehring's method and descriptive statistics. The project was approved by a Research Ethics Committee. Results: title, definition and seven risk factors were validated as "very important": physical immobilization, pressure, surface friction, shearing forces, skin moisture, alteration in sensation and malnutrition. Among the other risk factors, 11 were validated as "important": dehydration, obesity, anemia, decrease in serum albumin level, prematurity, aging, smoking, edema, impaired circulation, and decrease in oxygenation and in tissue perfusion. The risk factor of hyperthermia was discarded. Conclusion: the content validation of these components of the nursing diagnosis corroborated the importance of the same, being able to facilitate the nurse's clinical reasoning and guiding clinical practice in the preventive care for pressure ulcers.

Identification and definition of the components of the new nursing diagnosis should aid nurses to prevent pressure ulcer events.

Objective:To identify the nursing care prescribed for patients in risk for pressure ulcer (PU) and to compare those with the Nursing Interventions Classification (NIC) interventions. Method: Cross mapping study conducted in a university hospital. The sample was composed of 219 adult patients hospitalized in clinical and surgical units. The inclusion criteria were: score ≤ 13 in the Braden Scale and one of the nursing diagnoses, Self-Care deficit syndrome, Impaired physical mobility, Impaired tissue integrity, Impaired skin integrity, Risk for impaired skin integrity. The data were collected retrospectively in a nursing prescription system and statistically analyzed by crossed mapping. Result: It was identified 32 different nursing cares to prevent PU, mapped in 17 different NIC interventions, within them: Skin surveillance, Pressure ulcer prevention and Positioning. Conclusion: The cross mapping showed similarities between the prescribed nursing care and the NIC interventions.

Objective: To identify clinical evidence of the nursing diagnosis Adult pressure injury. Method: 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.

Resumo Objetivos selecionar os indicadores dos resultados de enfermagem Integridade tissular: pele e mucosas (1101) e Cicatrização de feridas: segunda intenção (1103) da Nursing Outcomes Classification e construir suas definições conceituais e operacionais para a avaliação de pacientes com lesão por pressão. Métodos estudo de consenso de especialistas realizado em hospital universitário em setembro/2018. Participaram no estudo 10 enfermeiros com experiência na utilização da Nursing Outcomes Classification e no cuidado ao paciente com lesão por pressão. A coleta de dados ocorreu por meio de encontro presencial com os especialistas. Resultados Foram selecionados 17 indicadores da Nursing Outcomes Classification para a avaliação do paciente com lesão por pressão, com uma concordância de 100% entre os especialistas. São eles: Branqueamento, Eritema, Sensibilidade, Perfusão tissular, Hidratação/ Descamação, Espessura, Necrose, Odor desagradável na ferida, Pele com bolhas, Pele macerada, Descolamento Sob as bordas da Ferida, Inflamação Da Ferida, Exsudato/Drenagem, Granulação, Tunelamento, Formação de cicatriz e Tamanho da ferida. Conclusão e implicações para a prática os indicadores selecionados permitiram a elaboração de um instrumento que auxiliará na avaliação de pacientes com lesão por pressão de forma acurada. Esse instrumento subsidiará o enfermeiro na tomada de decisão diagnóstica e terapêutica da lesão por pressão.