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.

Objective: to evaluate the complications of percutaneous renal biopsy based on outcomes and clinical indicators of the Nursing Outcomes Classification. Method: a prospective longitudinal study. The sample consisted of 13 patients submitted to percutaneous renal biopsy, with 65 evaluations. The patients were evaluated in five moments in the 24 hours after the procedure, using an instrument developed by the researchers based on five outcomes (Blood coagulation, Circulation status, Blood loss severity, Pain level, Comfort status: Physical) and 11 indicators. The Generalized Estimation Equation Test was used to compare the scores of the indicators. The project was approved by the institutional ethics committee. Results: in the 65 evaluations, a statistically significant difference was identified in the reduction of the scores of the following nursing outcomes: Blood coagulation, “hematuria” indicator; Circulation status, in the “systolic blood pressure and diastolic blood pressure” indicators and Comfort status: physical, in the “physical well-being” indicator. Conclusion: the evaluated patients did not show major complications. The clinical indicators signaled changes in circulation status, with reduced blood pressure, as well as in blood clotting observed by hematuria, but without hemodynamic instability. The comfort status was affected by the rest time after the procedure.

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.