INTENSIVA OCCURRENCE AND RISK FACTORS FOR PRESSURE INJURIES IN INTENSIVE CARE CENTERS

Objective: to describe the frequency and risk factors for development of pressure injuries (PIs) in clients of Intensive Care Centers. Method: quantitative, cross-sectional study of a sample of 104 clients from a population of 936 subjects from two public teaching hospitals assisted between March and June 2016. Data were collected using an observation form based on national and international guidelines, and descriptive statistical analysis was performed with a significance level of 5%. The results are presented as absolute and relative values, in tables, and the association between variables was calculated. Results: among the studied variables, age equal to or greater than 60 years, presence of hyperthermia and presence of swollen skin were the ones that had statistically significant effect on the occurrence of PIs. Conclusion: the risk factors identified as significant for the occurrence of PI can be prevented and, thus, the involvement of the nursing team is fundamental to prevent these lesions. Descriptors: Pressure Injury; Patient safety; Intensive Care Units; Nursing; Health Care; Critical Care. RESUMEN Objetivo: describir la frecuencia y los factores de riesgo para el desarrollo de lesiones por presión en clientes de Centros de Terapia Intensiva. Método: estudio cuantitativo, transversal, realizado en una muestra de 104 clientes de una población de 936 sujetos de dos hospitales públicos de enseñanza, atendidos entre los meses de marzo a junio de 2016. Los datos fueron recogidos con el uso de un formulario de observación basado en directrices nacionales e internacionales, y el análisis estadística descriptiva fue realizada con adopción de un nivel de significancia de 5%. Los resultados son presentados en planillas en valores absolutos y relativos, y cálculos para verificación de asociación entre las variables. Resultados: entre las variables estudiadas, la edad fue igual o mayor a 60 años, la presencia de hipertermia y de piel con edema fueron las que presentaron significancia estadística con la ocurrencia de LP. Conclusión: los factores de riesgo identificados como significativos para la ocurrencia de LP pueden ser prevenidos, por lo tanto, el envolvimiento del equipo de enfermería es fundamental en la prevención de esas lesiones. Descriptores: Úlcera por Presión; Seguridad del Paciente; Unidades de Cuidados Intensivos; Enfermería; Atención de Salud; Cuidados Críticos. Mestre, Hospital Universitário da Universidade Federal da Grande Dourados/UFGD. Dourados (MS), Brasil. E-mail: paulaknoch@hotmail.com ORCID iD: http://orcid.org/0000-0002-5010-9579; Doutora, Programa de Mestrado em Enfermagem, Universidade Federal de Mato Grosso do Sul/UFMS. Campo Grande (MS), Brasil. E-mail: marisarolan@gmail.com ORCID iD: http://orcid.org/0000-0001-8795-5966; Doutor, Programa de Mestrado e Doutorado em Enfermagem, Universidade Federal do Rio Grande do Norte/UFRN. Campo Grande (MS), Brasil. E-mail: marcos_junior@ufms.br ORCID iD: https://orcid.org/0000-0002-9123-232X; Doutor, Programas de Mestrado e Doutorado em Saúde e Desenvolvimento na Região Centro-Oeste, Universidade Federal de Mato Grosso do Sul/UFMS. Campo Grande (MS), Brasil. E-mail: albertss@hotmail.com ORCID iD: http://orcid.org/0000-0003-0017-672X ARTIGO ORIGINAL Mendonça PK, Loureiro MDR, Ferreira Júnior MA et al. Ocorrência e fatores de risco para lesões... Português/Inglês Rev enferm UFPE on line., Recife, 12(2):303-11, fev., 2018 304 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i2a23251p303-311-2018 As lesões por pressão (LP) constituem um grave problema de saúde pública, principalmente em razão do impacto que causam à pessoa doente, sua família e para a sociedade. São consideradas indicadores de qualidade da assistência em saúde, que requerem a implementação de intervenções para sua prevenção e tratamento. Nos Centros de Terapia Intensiva (CTI) este evento consiste em um problema frequentemente encontrado. Na prática cotidiana, sua evolução é rápida e pode trazer complicações ao indivíduo hospitalizado, além de prolongar seu tempo de tratamento e reabilitação. Um estudo brasileiro realizado em dois CTI de um hospital privado do estado do Rio Grande do Norte demonstrou uma incidência de LP em clientes hospitalizados de 50,0%. Ressalta-se que o desenvolvimento dessas lesões pode gerar também processos judiciais, tanto para as instituições quanto para os profissionais de saúde. A prevenção de LP é um desafio para a equipe multiprofissional, requer uma equipe de enfermagem qualificada para identificar os fatores de risco, de forma a planejar e implementar medidas eficazes para a prevenção e tratamento. Os fatores de risco para o desenvolvimento de LP podem ser divididos em extrínsecos e intrínsecos. Os extrínsecos são aqueles derivados do ambiente, externos ao paciente. Os mais importantes são a pressão de contato sobre uma proeminência óssea, sua duração, a tolerância tecidual e o microclima. Os esforços para a elaboração e implantação de protocolos de prevenção de LP decorrente do Programa Nacional de Segurança do Paciente são notadamente crescentes nos hospitais brasileiros. A incidência de LP consiste em um indicador da qualidade da assistência de enfermagem. Entretanto, os hospitais ainda não têm uma cultura de segurança do cliente e apresentam dificuldades na implementação do trabalho de prevenção como prática prioritária, devido ao déficit de recursos humanos e materiais, da atuação da gerência de enfermagem, além da falta de capacitação dos profissionais. O enfermeiro tem como atribuição a elaboração e a implementação de protocolos preventivos, que inclui a avaliação periódica da adesão às medidas propostas, aplicação de indicadores clínicos, educação continuada, comprometimento com a qualidade e/ou melhoria de questões estruturais, organizacionais, de recursos humanos e materiais. Neste contexto, este estudo adotou a seguinte questão norteadora << Qual a ocorrência e os fatores de risco para o desenvolvimento de LP em clientes assistidos em CTI? >>. A magnitude dos dados epidemiológicos sobre a ocorrência de LP e os fatores de risco determinantes para o seu aparecimento em clientes internados em CTI constitui importante indicador de qualidade assistencial para a enfermagem, de forma a justificar a relevância deste estudo. ● Descrever a frequência e os fatores de risco para o desenvolvimento de lesões por pressão em clientes de Centros de Terapia Intensiva. Artigo elaborado a partir da dissertação << Lesões por pressão: ocorrências, fatores de risco e prática clínica preventiva dos enfermeiros em Centros de Terapia Intensiva >>, apresentada ao Curso de Mestrado Acadêmico em Enfermagem, da Universidade Federal de Mato Grosso do Sul. Campo Grande (MS), Brasil, 2017. Estudo quantitativo, descritivo, analítico, transversal, realizado com clientes atendidos em dois CTI adulto gerais de dois hospitais públicos de ensino de Campo Grande, Mato Grosso do Sul. A população estudada foi composta por todos os clientes atendidos pelos serviços estudados, num total de 936 sujeitos, cuja amostra foi selecionada por conveniência e incluiu os adultos com idade igual ou maior a 18 anos e com período de internação completo de 24 horas. Este critério mínimo de tempo de internação no setor foi estabelecido devido à evidência do risco de surgimento de LP a partir desse período. Foram excluídas as gestantes em razão dos aspectos fisiológicos relacionados ao posicionamento no leito, bem como os clientes provenientes de instituições de longa permanência pela dificuldade de obtenção dos dados, além dos politraumatizados, como forma de manter a homogeneidade entre os participantes das duas instituições elegíveis para o estudo. A amostra final foi constituída por 104 participantes e a coleta de dados foi realizada entre os meses de março a junho de 2016. Para coleta dos dados, aplicou-se um formulário de observação, utilizado uma única vez, após completadas 24 horas de internação no CTI, para a realização da avaliação dos MÉTODO OBJETIVO INTRODUÇÃO Mendonça PK, Loureiro MDR, Ferreira Júnior MA et al. Ocorrência e fatores de risco para lesões... Português/Inglês Rev enferm UFPE on line., Recife, 12(2):303-11, fev., 2018 305 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i2a23251p303-311-2018 clientes e coleta de informações nos prontuários. O roteiro de observação elaborado foi adaptado a partir de tópicos relevantes relacionados à prevenção de LP e segurança do cliente citados em diretrizes nacionais e internacionais. O formulário elaborado foi submetido à avaliação e aprovado por três especialistas em LP quanto à observância dos seguintes critérios: clareza, pertinência, conteúdo e proposição de sugestões. Foi aplicado um préteste em três clientes da Unidade Coronariana de uma das instituições estudadas. Os participantes desse pré-teste também assinaram o Termo de Consentimento Livre e Esclarecido (TCLE). As variáveis elegíveis foram categorizadas em dois grupos: 1) de identificação: sexo, cor, faixa etária e Índice de Massa Corporal (IMC); e 2) relacionadas à avaliação dos fatores de risco: temperatura, resultado de exame laboratorial (hemoglobina e leucócitos), estado nutricional, condições da pele, enchimento capilar, ventilação mecânica, estado geral de saúde, eliminações fisiológicas, uso de drogas vasoativas, tipo de colchão em uso e condições dos lençóis. Os dados coletados foram armazenados em planilhas no Programa Microsoft Office Excel, versão 2010. A análise foi realizada por meio do programa estatístico Statistical Package for the Social Sciences (SPSS), versão 23.0, com uso de estatística descritiva e dos testes qui-quadrado ou exato de Fisher de acordo com as variáveis analisadas, além do uso do teste estatístico de Odds Ratio para verificação da razão de chances. O nível de significância adotado para o estudo foi de 5%. Os resultados foram apresentados em formato de tabelas com frequências absoluta e relativa, além dos cálculos para verificação de as

Pressure injuries (PIs) represent a serious public health problem, mainly because of the impact they cause to the sick persons, their families and society.They are considered quality indicators of health care and require interventions for their prevention and treatment. 1essure injuries are a frequent problem in Intensive Care Centers (ICCs).In the daily practice, the evolution of PIs is rapid and can bring complications to the hospitalized patient, in addition to prolonging the time needed for treatment and rehabilitation. 2Brazilian study performed in two ICCs of a private hospital in the state of Rio Grande do Norte showed an incidence of PIs of 50.0% in hospitalized clients. 3 should be emphasized that the development of PIs can also lead to lawsuits against both institutions and health professionals.PI prevention is a challenge for the multiprofessional team.It requires a qualified nursing team to identify the risk factors in order to plan and implement timely and effective prevention and treatment measures. 4sk factors for PI development can be divided into extrinsic and intrinsic.Extrinsic factors are those derived from the environment, external to the patient.The most important are contact pressure on bony prominences, duration of this pressure, tissue tolerance, and microclimate. 5forts to develop and implement PI prevention protocols resulting from the National Patient Safety Program have notably increased in Brazilian hospitals.The incidence of pressure injuries is a quality indicator of nursing care.However, hospitals do not yet have a client safety culture and present difficulties to implement a prevention work as a priority practice.This is due to lack of human and material resources, the quality of nursing management, and lack of professional training. 6rses are responsible for the elaboration and implementation of preventive protocols, including periodic evaluation of adherence to the proposed measures, application of clinical indicators, continuing education, commitment to quality and/or improvement of structural, organizational and human resources and materials. 7 this context, this study adopted the following guiding question << What is the incidence of PIs and the associated risk factors in ICC-assisted clients?>>.The magnitude of epidemiological data on the occurrence of PIs and the risk factors determining its appearance in ICC clients is an important indicator of nursing care quality, and justify the relevance of the present study.The study population consisted of all the clients assisted in the studied services, consisting of a total of 936 subjects.The sample was selected for convenience and included adults aged 18 years or over and with at least 24 hours of hospitalization.This criterion of minimum hospitalization time in the sector was adopted due to evidence that the risk of PI occurrence starts over that time.Pregnant women were excluded due to physiological aspects related to bed positioning, as well as the clients coming from long-term care institutions due to the difficulty of obtaining the data, besides the polytraumatized patients as a way to maintain homogeneity among participants of the two institutions eligible for the study.The final sample consisted of 104 participants and data collection was performed between March and June 2016.
For data collection, a one-time observation form was applied after 24 hours of hospitalization at the ICC, for evaluation of clients and collection of information from medical records.The observation script was adapted from relevant topics related to PI prevention and client safety cited in national and international guidelines.
The form was submitted to evaluation and approved by three PI experts regarding the following criteria: clarity, pertinence, content and suggestions.A pre-test was applied to three clients of the Coronary Unit of one of the institutions studied.The sample consisted of 104 clients from the two institutions studied, with 45 from the public Institution 1 and 59 from the philanthropic Institution 2 which serves the Unified Health System.During the period, a total of 192 hospitalizations were recorded in the Institution 1 and 744 in the Institution 2, amounting to a total of 936 subjects.
Despite the greater flow of clients in the institution 2, several aspects limited their inclusion in the study, such as the high frequency of hospitalizations for polytrauma and clients referred from cities of the countryside of the state of Mato Grosso do Sul (MS).This aspect led to the reduction of the number of visits and consequent difficulty to obtain the consent for inclusion in the research.
Another aspect was the hospitalization of clients coming from longterm care institutions.
Table 1 shows the association between the characteristics of the sample and the occurrence of PIs.A proportion of 53.8% (56) of the sample corresponded to male subjects and no statistically significant association was found regarding skin color and PI outcome.As for age group, 55.8% (58) was aged over 59 years, with a statistically significant influence of this variable over the occurrence of PI (p = 0.032).
Regarding BMI, the majority (66.7%) of participants were classified as eutrophic (30), excluding those whose information was missing in the medical record (59).The description of the sample and analysis of the The risk factors for PI that presented a statistically significant difference were hyperthermia (p = 0.029) and edema (p = 0.012).Temperature values and laboratory tests were collected from the medical record and the others were collected during the clinical evaluation.

English
Table 3 shows the relationship between the support surfaces and the occurrence of PIs, which affected 49.0% of the clients using pneumatic mattresses and 51.0% of those using a viscoelastic foam mattresses (p = 0.234).Regarding the bedsheet conditions, 82.4% of the clients who used non-compliant sheets and 17.6% of those who used compliant sheets presented PIs.Regarding the support surfaces used in the ICCs studied, it was possible to evaluate the sample individually.The institution 1 presented 91.1% (41) of the beds with pneumatic mattresses, and 8.9% (04) with viscoelastic foam mattresses.Institution 2 presented pneumatic mattresses in 5.1% (03) of the beds, and viscoelastic foam mattresses in 94.4% (56).There was a significant difference between the institutions (p < 0.001).
Regarding the bedsheet conditions of the clients studied in Institution 1, only 8.9% (04) were in accordance with the recommendations, while 91.1% (41) were not.In Institution 2, 37.3% (22) were compliant, and 62.7% (37) were non-compliant.There was a significant difference between the two institutions (p = 0.001).
Clients of both sexes presented PIs, with males representing 52.9% of the sample and females, 47.1%.The finding is in line with a prospective cohort study performed at a ICC in the city of Vitória, capital of the state of Espírito Santo, where 59% of the male population presented PIs. 8 A cross-sectional study carried out in a large university hospital in the South of Brazil in 2008, the female sex presented a higher occurrence of PIs. 9 This difference between studies may be related to the comorbidities of each client.In addition, there was a slight difference in the number of men in that sample.
Regarding the sociodemographic characteristics, there was a statistical difference between age groups, which showed more PIs in clients aged over 59 years (p = 0.032).In a study performed in a Brazilian hospital, PIs were found to be prevalent among elderly patients with a mean age of 67 years. 102] Despite this, it is noted that ICC patients often present other therapeutic priorities due to their critical clinical conditions that make it difficult to perform preventive care for PI.
Regarding skin color and the occurrence of PI, there was no statistical association between these variables (p = 0.308).The nonbleachable erythema known as Stage 1 PI can be difficult to identify in people with dark skin tones because the different color of the surrounding area may become unapparent, or pass undetected in the skin evaluation performed by an untrained professional.Such a condition may be indicative of risk. 13owever, there are still controversies regarding these variables in the literature. 8though the BMI values of all the clients studied were not available, there was no statistically significant association of this variable with the occurrence of PI (p = 0.754).This finding is similar to the cross-sectional, analytical study carried out in 2007 in a ICC in the state of Minas Gerais in which 50% of the PIs occurred in eutrophic patients, without statistical differences in the frequency of PI according to nutritional status (p = 0.179). 14A study conducted in the United States of America in the period from 2007 to 2010 with clients hospitalized in the ICC revealed that the BMI classifications stratified as low weight and important obesity represent a high risk for the occurrence of PI and deserved more attention than those patients with normal weight. 15These findings highlight the importance of this data in medical records, for it represents a predictor of risk for PI.
The presence of hyperthermia had a statistically significant association with the occurrence of PIs (p = 0.029).This differs from what was found (p = 0.137) in the study developed in an adult ICC at a public hospital of João Pessoa/PB in 2012. 5Microclimatic control is fundamental, since the increase in body temperature causes a potential impact on the risk of a individual developing PI. 13 Rigorous temperature control of ICC clients leads to important clinical reasoning related to the treatment and evolution of the disease.
Clients whose clinical manifestations presented edema and the occurrence of PI also had a significant association (p = 0.012).In the study carried out in João Pessoa, swollen skin showed no statistical association with PI (p = 0.896). 5However, the presence of edema compromises the diffusion of oxygen in the tissues, a factor that predisposes to the occurrence of PI. 16 Such an event is common in clients hospitalized in ICCs mainly due to impaired mobility, infusion of large volumes of fluids, and multiple organ dysfunctions.

DISCUSSION
Variables related to laboratory tests, specifically hemoglobin and leukocyte values, besides clinical findings such as capillary refill, mechanical ventilation, general condition, physiological eliminations, and the use of vasoactive drugs did not present a statistically significant correlation with the occurrence of PI in this study, similar to findings from another study. 5,8Despite the absence of statistical association, anemia affects the transport of oxygen and its effect on the immune system leads to a decrease in resistance and consequent infections, which may favor the development of PI. 16 The daily control of laboratory test values in critical clients aids the treatment and expresses clinical evolution.Mechanical ventilation did not represent a higher risk for PIs compared with spontaneous ventilation (p = 0.610).A study conducted in a ICC and Semi-Intensive unit in Rio Grande do Sul pointed to an association between the use of mechanical ventilation and the development of PIs. 17 However, it is known that the use of these aid may predispose to this sort of lesions due to factors such as immobility, pressure on bony prominences, and difficulty in maintaining adequate ventilation-perfusion, which impairs tissue oxygenation. 5It is important to note that poor tissue perfusion can also affect PI healing. 13lthough the use of mechanical ventilation in this study did not demonstrate a significant association with the occurrence of PI, frequent mobilization, adequate client positioning, and daily skin inspection are indispensable precautions to prevent these lesions.
The use of vasoactive drugs did not present a significant association with the presence of PI (p = 0.246), likewise a study carried out between 2013 and 2014 in a ICC of a public hospital in the state of São Paulo (p = 0.842). 18In general, the severity of the clinical state of ICC clients may require the use of vasoactive drugs due to hemodynamic instability, as well as other priority measures to maintain life.These measures interfere in a way to delay the evaluation of the risk for PI by health professionals that take care of the priorities of the cases, postponing the implementation of interventions to maintain skin integrity, such as decubitus change. 19linical evaluation and the association of technologies in PI prevention should be adopted mainly for the most serious clients.
The regular/poor general condition and the occurrence of PIs also did not present a statistically significant association (p = 1.000) for the outcome occurrence of PI in the clients studied.In a study conducted in 2009 in a CCI of a school hospital in the city of São Paulo, patients with high risk in the Braden Scale evaluation were 25.5 times more likely to develop PI compared to those with low risk, mainly due to their general state. 20Although the assessment of the general health status may present some subjectivity, such assessment in ICC clients is usuall regular or poor and demonstrates the importance of care, including the prevention of PIs.
No statistical association was found in relation to physiological eliminations and the occurrence of PIs when comparing continent patients using Long-term Indwelling Catheter (LIC) and/or incontinent patients (p = 0.742).However, it is known that skin damage resulting from moisture is a risk for PIs. 13 Although the use of LIC decreases the probability of humidity, the higher observed occurrence of PI can be due to the fact that the clients are in more severe clinical conditions and are consequently more likely to develop PIs.
Regarding the type of mattress used by the ICC clients studied, the occurrence of PIs was detected in 51% of those who used a viscoelastic foam mattresses compared to 49% of those who used a pneumatic mattresses (p = 0.234).The use of highly specific reactive foam mattresses is recommended instead of reactive foam mattresses of low specificity.Pneumatic mattresses with a diameter of less than 10 centimeters do not inflate enough air to ensure the relief of pressure on cells that are deflated.The choice of a type of support surface does not dispense frequent manual repositioning, especially in individuals at high risk for PI, which is the case of intensive care clients. 13eumatic mattresses are not always available in sufficient quantity in hospitals to meet the demand.So, nurses indicate them only to some priority clients, according to the risk for PI identified in their evaluations.In the case of clients with indication for use of such mattresses, it is usual to suggest the family to purchase the mattress, what will depend on financial availability.nonconformities, but without presenting statistical significance (p = 0.114) in the results of this study.Moisture, dirt and wrinkles in the sheets should be avoided in the provision of nursing care, for the presence of these factors increases the risk for PIs. 6The findings of this study demonstrate the importance of inspecting sheets at each mobilization in the bedside, and exchanging sheets is recommended whenever necessary. 6fective nursing interventions for PI prevention in ICC clients involve careful and individualized assessment that addresses the real needs of clients and the decision-making of nurses on skin care of critical clients. 21e occurrence of PI was more frequent in patients aged over 59 years who presented hyperthermia and swollen skin as the main risk factors.It was observed that skin care is insufficient in ICC settings for clients with compromised clinical conditions and when therapeutic priorities overlap the actions of prevention of such injuries.It is essential that the institutions prioritize the elaboration and implementation of prevention protocols to improve the quality of care.
Permanent education of nursing professionals on the subject would enable an approach to prevention, according to the needs of the services and the management of care based on scientific evidence.Further research is needed on the subject, with larger populations in peculiar situations, besides the detailed analysis of each risk factor for the incidence of PIs.
Federal University of Mato Grosso do Sul/UFMS.
• To describe the frequency and risk factors for development of pressure injuries in clients of Intensive Care Centers.

The participants of MÉTHOD OBJECTIVE INTRODUCTION
The protocol of this research was approved in its ethical and methodological aspects by the Ethics Committee for Research with Human Beings of the UFMS, under the Consubstantiated Opinion nº 1,300,163/2015 and the Certificate of Presentation for Ethical Appreciation (CAAE) nº 50011615.6.0000.0021.All clients invited to participate in the study were informed about the purpose of the work and had the confidentiality of the provided information guaranteed.The ICF was signed by participants or their legal guardians in cases of clients in situation of substantial decreased cognitive discernment and capacity of the motor speech apparatus.The Term of Commitment for the Use of Information from Medical Records was signed by the main researcher, in accordance with Resolution nº 466/2012of the National Health Council.

Table 1 .
Occurrences of pressure injuries in clients hospitalized in Intensive Care Centers of two teaching hospitals.Campo Grande/MS, 2017 (n=104).

Table 2 .
Relationship between risk factors and occurrence of pressure injuries in clients hospitalized in Intensive Care Centers of two public teaching hospitals.Campo Grande/MS, 2017 (n=104).Fisher' exact test or Chi square.Different letters indicate a statistically significant difference in the occurrence of Pressure Injury (p <0.05).

Table 3 .
Relation between the support surfaces and the occurrence of pressure injuries in clients hospitalized in Intensive Care Centers of two public teaching hospitals.Campo Grande/MS, 2016 (n=104).