Keywords
Nursing Records
Pressure Injury
Pressure Ulcer
Primary Health Care
How to Cite
Abstract
Introduction. Pressure injuries represent a prevalent and serious health issue among dependent individuals, especially within the primary care context. These injuries contribute to increased morbidity, diminished quality of life, and greater healthcare resource utilization. Accurate and comprehensive clinical records are essential not only for guiding individual patient care but also for supporting scientific research. They enable the identification of risk factors, monitoring of outcomes, and development of evidence-based interventions. The Aim of this study is to analyse the informatic nursing records of dependent persons in a Portuguese Primary Health Care Unit (PHCU), within the scope of the prevention and treatment of pressure ulcers/injuries (PU/PI).
Methods. Retrospective analysis of electronic health record database from 112 patients registered in the “Dependents Program” of the Informatic System SClínico® of a Portuguese Primary Health Care Unit during 2019. Beyond sociodemographic characterization, the data analysis included the following variables: self-care level; PU/PI risk; co-morbidities; nutritional risk; PU/PI classification, anatomical location, assessment, and type of treatments performed; pain and the family caregiver’s “ability” and “knowledge” to prevent PU/PI.
Results. During 2019, 80.4% of the participants had the self-care level recorded and 83.0% had the PU/PI risk assessment recorded. The nutritional risk assessment was not recorded in 90.2% of the participants. The PU/PI assessment through RESVECH 2.0 was registered in 72.2% of the participants. The treatment implemented and the pain assessment were documented in a residual way.
Discussion and Conclusions. The findings reveal notable strengths and gaps in the documentation practices related to pressure injury prevention and management in primary care. While a majority of participants had their self-care level and PU/PI risk assessments recorded, critical areas such as nutritional risk assessment were largely neglected. Given the well-established link between nutrition and skin integrity, this represents a significant oversight. The use of the RESVECH 2.0 tool for PU/PI assessment was observed in great percentage of participants, indicating moderate integration of standardized assessment tools into clinical practice. However, the documentation of both treatment interventions and pain assessment was minimal, suggesting these essential aspects of care are not being systematically recorded. These findings underscore the need to strengthen comprehensive and consistent record-keeping, as incomplete documentation can hinder both the continuity of care and the generation of robust scientific evidence.
References
1. Machado AMSF, Oliveira BF, Alves IMT da, Sardo PMG. Prevalence and incidence of pressure ulcers/injuries in emergency services: a systematic review protocol. J Tissue Viability. 2022;31(1):58–61. https://doi.org/10.1016/j.jtv.2021.10.005
2. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers/injuries: clinical practice guideline. 2019.
3. Sardo P, Guedes J, Alvarelhão J, Machado P, Melo E. Pressure ulcer incidence and Braden subscales: retrospective cohort analysis in general wards of a Portuguese hospital. J Tissue Viability. 2018;27:95–100. https://doi.org/10.1016/j.jtv.2018.01.002
4. Dealey C, Brindle C, Black J, et al. Challenges in pressure ulcer prevention. Int Wound J. 2015;12(3):309–312. https://doi.org/10.1111/iwj.12107
5. Sardo P, Simões C, Alvarelhão J, et al. Pressure ulcer risk assessment: retrospective analysis of Braden Scale scores in Portuguese hospitalised adult patients. J Clin Nurs. 2015;24:3165–3176. https://doi.org/10.1111/jocn.12927
6. Instituto Nacional de Estatística. Statistics Portugal - Portal do INE. Published 2020. Accessed April 18, 2021. https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_indicadores&indOcorrCod=0001273&contexto=bd&selTab=tab2
7. Lima MIV de O, Pereira J de KC, Soares FC, et al. Lesão por pressão em pacientes acamados com idade avançada e os cuidados de enfermagem: uma revisão integrativa da literatura. Res Soc Dev. 2021;10(5):e16310513373. https://doi.org/10.33448/rsd-v10i5.13373
8. Quirino DÉS, Faustino AM, Freitas RO, Oliveira AB, Medved IV. Fatores de risco para o desenvolvimento de úlcera por pressão em unidade de internação clínica. Rev Estima. 2014;12(4). https://www.revistaestima.com.br/index.php/estima/article/view/99
9. Sardo PMG, Teixeira JPF, Machado AMSF, Oliveira BF, Alves IM. A systematic review of prevalence and incidence of pressure ulcers/injuries in hospital emergency services. J Tissue Viability. 2023. https://doi.org/10.1016/j.jtv.2023.02.001
10. Sardo P, Simões C, Alvarelhão J, et al. Analyses of pressure ulcer point prevalence at the first skin assessment in a Portuguese hospital. J Tissue Viability. 2016;25:75–92. https://doi.org/10.1016/j.jtv.2016.02.006
11. Sardo P, Simões C, Alvarelhão J, et al. Analyses of pressure ulcer incidence in inpatient setting in a Portuguese hospital. J Tissue Viability. 2016;25:209–215. https://doi.org/10.1016/j.jtv.2016.08.003
12. Direção-Geral da Saúde. Escala de Braden: versão adulto e pediátrica (Braden Q). 2011. https://www.dgs.pt/departamento-da-qualidade-na-saude/ficheiros-anexos/orientacao_ulceraspdf-pdf.aspx
13. Gomes F, Corte A, Monteiro A, Loureiro H. A vivência das medidas de prevenção da recidiva da úlcera venosa: um estudo qualitativo. Investig Qual Saúde Avanços Desafios. 2022;13. https://doi.org/10.36367/ntqr.13.2022.e653
14. Rodrigues AM, Ferré-Grau C, Ferreira PL. Being an informal caregiver of a person with a pressure ulcer in the Azores Islands. Adv Skin Wound Care. 2015;28(10):452–459. https://doi.org/10.1097/01.ASW.0000471191.11548.dd
15. Rodrigues AM, Ferreira PL, Ferré-Grau C. Providing informal home care for pressure ulcer patients: how it affects carers’ quality of life and burden. J Clin Nurs. 2016;25(19-20):3026–3035. https://doi.org/10.1111/jocn.13356
16. Registered Nurses’ Association of Ontario. Pressure injury management: risk assessment, prevention and treatment. 4th ed. 2024.
17. Sardo PMG, Macedo RPA, Alvarelhão JJM, et al. Nursing workload assessment in an intensive care unit: a retrospective observational study using the Nursing Activities Score. Nurs Crit Care. 2023;28:288–297. https://doi.org/10.1111/nicc.12854
18. Crisan EL, Mihaila A. Health-care information systems adoption – a review of management practices. Vilakshan XIMB J Manag. 2023;20(1):130–139. https://doi.org/10.1108/XJM-04-2021-0121
19. Beauchamp TL, Childress JF. Princípios de Ética Biomédica. Loyola; 2002.
20. Cascão TRV, Rasche AS, Di Piero KC. Incidência e fatores de risco para lesão por pressão em unidade de terapia intensiva. Rev Enferm Atual. 2017:1–8. http://revistaenfermagematual.com/index.php/revista/article/view/204/105
21. Laranjeira CA, Loureiro S. Fatores de risco das úlceras de pressão em doentes internados num hospital português. Rev Salud Publica. 2017;19(1):161–170. https://doi.org/10.15446/rsap.v19n1.42251
22. Souza NR de, Freire D de A, Souza MA de O, et al. Fatores predisponentes para o desenvolvimento da lesão por pressão em pacientes idosos: uma revisão integrativa. Rev Estima. 2017;15(4):229–239. https://doi.org/10.5327/z1806-3144201700040007
23. Lopes T, Videira L, Saraiva D, et al. Multicentre study of pressure ulcer point prevalence in a Portuguese region. J Tissue Viability. 2020;19(1):2–18. https://doi.org/10.1016/j.jtv.2019.11.002
24. Silva ACF. Habilidades do Cuidador Informal para Cuidar da Pessoa Dependente no Autocuidado. 2019.
25. Gonçalves C. Dificuldades do Cuidador Informal do Idoso Dependente. 2019.
26. Petronilho F, Pereira F, Silva A. Evolução e destino das pessoas dependentes no autocuidado: estudo longitudinal. Rev Investig Enferm. 2017;18(2ª série):32–42.
27. Farid J, Amin R, Sheikh MA, et al. Prevalence and prediction of pressure ulcers in admitted stroke patients in a tertiary care hospital. J Tissue Viability. 2022;31(4):768–775. https://doi.org/10.1016/j.jtv.2022.07.010
28. Chen Z, Gleason LJ, Sanghavi P. Accuracy of pressure ulcer events in US nursing home ratings. Med Care. 2022;60(10):775–783. https://doi.org/10.1097/MLR.0000000000001763
29. Fundação Francisco Manuel dos Santos. PORDATA - Base de Dados Portugal Contemporâneo. 2022. https://www.pordata.pt/portugal/
30. Aguiar ESS, Soares MJGO, Caliri MHL, et al. Avaliação da capacidade funcional de idosos associada ao risco de úlcera por pressão. Acta Paul Enferm. 2012;25:94–100.
31. Faustino S. A Saúde dos Cuidadores Familiares de Idosos Dependentes: um projeto de intervenção de enfermagem comunitária na UCC de Vila Franca de Xira. Published online 2017.
32. Trindade I, Almeida D, Romão M, et al. Caracterização do grau de sobrecarga dos cuidadores de utentes dependentes da Unidade de Saúde Familiar USF Descobertas. Rev Port Med Geral Fam. 2017;33(3):178–186. https://doi.org/10.32385/rpmgf.v33i3.12160
33. Mello TV, Xavier TB da C, Almeida RG, et al. Estratificação de risco para desenvolvimento de úlceras de pressão e sua associação com a independência funcional de pacientes hospitalizados. ASSOBRAFIR Ciência. 2017;8(1):31–41.
34. Lopes C de FL. Úlceras por pressão em unidades de longa duração e manutenção. Published online 2017. https://bibliotecadigital.ipb.pt/bitstream/10198/14587/1/Relatório%20de%20Estágio%20-%20Carolina%20Lopes.pdf
35. Rodrigues AM, Soriano JV. Fatores influenciadores dos cuidados de enfermagem domiciliários na prevenção de úlceras por pressão. Rev Enferm Ref – III Série. 2011;5:55–63.
36. ACeS Entre Douro e Vouga I. Norma de Procedimentos de Enfermagem: aplicação da escala de Braden – versão adulto e pediátrica (Braden Q). 2019.
37.Marques TRL. Avaliação nutricional de idosos dependentes na mobilidade na USF Flor de Sal: o papel do enfermeiro de família. Published online 2016. https://ria.ua.pt/bitstream/10773/17317/1/Dissertação.pdf
38. Pestana IN. Risco de desnutrição na admissão hospitalar: estudo comparativo entre NRS-2002 e MNA. Published online 2019. https://doi.org/10.1017/CBO9781107415324.004
39. Vieira CP de B, Sá MS, Madeira MZDA, Luz MHBA. Caracterização e fatores de risco para úlceras por pressão na pessoa idosa hospitalizada. Rev da Rede Enferm do Nord. 2014;15(4):650–658. https://doi.org/10.15253/2175-6783.2014000400012
40. Alves DF dos S, Almeida AO de, Silva JLG, Morais FI, Dantas SRPE, Alexandre NMC. Tradução e adaptação do Bates-Jensen Wound Assessment Tool para cultura brasileira. Texto Context Enferm. 2015;24(3):826–833. https://doi.org/10.1590/0104-07072015001990014
41. Lyder CH. Pressure ulcer prevention and management. JAMA. 2003;289(2):223–226. https://doi.org/10.1001/jama.289.2.223
42. Rocha AP, Dias M. Úlceras por pressão: prevalência em contexto domiciliário. Published online 2019. https://usiterceira.azores.gov.pt/upp.html
43. Agreda JS, Bou JT, Soriano JV, et al. 2nd National Study of Pressure Ulcer Prevalence in Spain, 2005: epidemiology and definitive wound and patient variables. Gerokomos. 2006;17(3):154–172. https://doi.org/10.4321/S1134-928X2006000300006
44. Pieper B. Pressure ulcers: prevalence, incidence, and implications for the future. 2nd ed. National Pressure Ulcer Advisory Panel; 2012.
45. Briggs M, Collinson M, Wilson L, et al. The prevalence of pain at pressure areas and pressure ulcers in hospitalised patients. BMC Nurs. 2013;12(1):19. https://doi.org/10.1186/1472-6955-12-19
46. Cabello-Granado PA, Arévalo-Velasco JM. Estimation of the sanitary cost of bedsores (pressure sores) in patients with medullary lesions. Rev Gerenc Polit Salud. 2016;15(30):60–67. https://doi.org/10.11144/Javeriana.rgyps15-30.ecsu
47. Smith IL, Brown S, McGinnis E, et al. Exploring the role of pain as an early predictor of category 2 pressure ulcers: a prospective cohort study. BMJ Open. 2017;7(1):e013623. https://doi.org/10.1136/bmjopen-2016-013623
48. Cruz DM da. Do risco ao desenvolvimento de úlceras por pressão: a realidade de um serviço de medicina. Published online 2015. https://estudogeral.sib.uc.pt/handle/10316/28501
49. Gunningberg L, Hommel A, Bååth C, Idvall E. The first national pressure ulcer prevalence survey in county council and municipality settings in Sweden. J Eval Clin Pract. 2013;19(5):862–867.
50. Vanderwee K, Clark M, Dealey C, Gunningberg L, Defloor T. Pressure ulcer prevalence in Europe: a pilot study. J Eval Clin Pract. 2007;13(2):227–235.
51. Lahmann NA, Halfens RJG, Dassen T. Pressure ulcers in German nursing homes and acute care hospitals: prevalence, frequency and ulcer characteristics. Ostomy Wound Manag. 2006;52(2):20–33. http://www.pressureulcer.net/pressure-ulcers-in-nursing-homes/
52. Pancorbo‑Hidalgo PL, García‑Fernández FP, Bou J‑E, Soriano JV, Soldevilla‑Agreda JJ. Epidemiología de las úlceras por presión en España en 2013: 4.º estudio nacional de prevalencia. Gerokomos. 2014;25(4):162–170. https://doi.org/10.4321/s1134-928x2014000400006
53. Vieira C, Cação C, Neves C, Costa D, Santarém I. A qualidade dos cuidados na prevenção, monitorização e registo de úlceras de pressão no CHMT. Published online 2014:1–59. https://www.ordemenfermeiros.pt/arquivo/projectos/Documents/Projetos_Melhoria_Qualidade_Cuidados_Enfermagem/CentroHospitalarMedioTejo_QualidadeCuidadosPrevencaoMonitorizacaoRegistoUlcerasPressao.pdf
54. Yashchuk S. Estratégias na prevenção de úlceras por pressão: revisão integrativa da literatura. Published online 2019.
55. Alves P, Mota F, Ramos P, Vales L. Epidemiologia das úlceras de pressão: interpretar dados epidemiológicos como indicador de qualidade. Servir. Published online 2013.
56. Antunes J, Carvalho P, Freire T, Marques F. Registos de enfermagem e evolução cicatricial de feridas. J Aging Innov. 2015;4(2):3–10.
57. Santo PF do E, Almeida SA de, Silveira MM, Salomé GM, Ferreira LM. Uso da ferramenta Pressure Ulcer Scale for Healing para avaliar a cicatrização de úlcera crônica de perna. Rev Bras Cir Plástica. 2013;28(1):133–141. https://doi.org/10.1590/S1983-51752013000100023
58. Lourenço MCP. Avaliação da ferida crónica. Published online 2016.
59. Rodrigues A, Ferreira L, Lourenço C, Alves P, Marques J, Sá L. Chronic wound assessment: cultural and linguistic adaptation for European Portuguese of RESVECH-2 scale. J Tissue Viability. 2022;31(4):783–789. https://doi.org/10.1016/j.jtv.2022.07.004
60. Andersson J, Imberg S, Rosengren K. Documentation of pressure ulcers in medical records at an internal medicine ward in a university hospital in western Sweden. Nurs Open. 2023;10(3):1794–1802. https://doi.org/10.1002/nop2.1439
61. Luz SR, Lopacinski AC, Fraga R, Urban C de A. Úlceras de pressão. Geriatr Gerontol. 2010;4(1):36–43.
62. Silvestre MCC. Os registos de enfermagem: um olhar sobre o estado real da saúde das pessoas? Sobre Determ da Saúde. Published online 2012:1–47.
63. Rodrigues A, Soriano JV. A implicação do cuidador familiar na prevenção das úlceras por pressão. Rev Evidências. 2015;(no 1):24–34. https://comum.rcaap.pt/handle/10400.26/13931
64. Dopierała L, Szewczyk M, Cierzniakowska K, Cwajda J, Popow A, Wyrzykowska M. Level of preparation for preventive procedures and pressure ulcer treatment in health care units from the Kujawsko‑Pomorski region. Adv Med Sci. 2007;52(Suppl 1):81–84.
65. Direção-Geral da Saúde. A Dor como 5.º sinal vital: registo sistemático da intensidade da dor. Circ Norm no 09/DGCG. Published online 2003. https://doi.org/10.1017/CBO9781107415324.004