PRESSURE INJURY DEVELOPMENT AND CARE COMPLEXITY IN PATIENTS AT AN EMERGENCY SERVICE

ABSTRACT

Objective:

to assess pressure injury development and its association with care complexity in patients treated at an emergency service.

Method:

a prospective cohort and observational study conducted from August to October 2020 with patients treated in the emergency unit from a public hospital in southwest Bahia, Brazil. A specific form created for the study, the Braden Scale and the Perroca Classification Instrument were used for data collection. The data were analyzed by means of descriptive analysis and the Pearson’s chi-square test.

Results:

the sample consisted in 225 patients. The incidence of pressure injury was 9.3%. It mainly affected women (61.9%) in the intermediate (57.1%) and semi-intensive (42.9%) care levels. There was an association between care complexity and pressure injury development (p<0.001).

Conclusion:

the importance of evaluating care complexity in the patients treated at the emergency services is emphasized to provide safe care and reduce adverse events.

DESCRIPTORS:
Pressure Injury; Emergency Nursing: Patient Safety; Nursing Assessment; Nursing Care.

RESUMO

Objetivo:

avaliar o desenvolvimento de lesão por pressão e sua associação com a complexidade assistencial em pacientes atendidos em um serviço de emergência.

Método:

estudo de coorte prospectiva, observacional, realizado de agosto a outubro de 2020, com pacientes atendidos em uma unidade de emergência de um hospital público do Sudoeste da Bahia - BR. Para coleta de dados utilizou-se formulário próprio, Escala de Braden e Instrumento de Classificação de Perroca. Os dados analisados por análise descritiva e teste de qui-quadrado de Pearson.

Resultados:

a amostra foi constituída de 225 pacientes. A incidência de lesão por pressão foi de 9,3%. Acometendo principalmente mulheres (61,9%), em cuidados intermediários (57,1%) e semi-intensivos (42,9%). Houve associação entre complexidade assistencial e o desenvolvimento de lesão por pressão (p<0,001).

Conclusão:

destaca-se a importância da avaliação da complexidade assistencial dos pacientes atendidos nos serviços de emergência para proporcionar um cuidado seguro e reduzir eventos adversos.

DESCRITORES:
Lesão por Pressão; Enfermagem em Emergência; Segurança do Paciente; Avaliação em Enfermagem; Cuidados de Enfermagem.

RESUMEN

Objetivo:

evaluar el desarrollo de lesiones por presión y su asociación con la complejidad asistencial en pacientes atendidos en un servicio de emergencia.

Método:

estudio de cohorte prospectivo y observacional realizado entre agosto y octubre de 2020 con pacientes atendidos en la unidad de emergencias de un hospital público del sudoeste de Bahía, Brasil. Para recolectar los datos se utilizó un instrumento propio, la escala Braden y el Instrumento de Clasificación de Perroca. Los datos se analizaron por medio de análisis descriptivo y de la prueba chi-cuadrado de Pearson.

Resultados:

la muestra estuvo conformada por 225 pacientes. La incidencia de lesiones por presión fue del 9,3% y afectó principalmente a mujeres (61,9%), en los niveles de cuidados intermedios (57,1%) y semi-intensivos (42,9%). Se registró una asociación entre la complejidad asistencial y el desarrollo de lesiones por presión (p<0,001).

Conclusión:

se destaca la importancia de evaluar la complejidad asistencial de los pacientes atendidos en los servicios de emergencia para proporcionar una atención segura y reducir la cantidad de eventos adversos.

DESCRIPTORES:
Lesiones por Presión; Enfermería en Emergencias; Seguridad del Paciente; Evaluación en Enfermería; Atención de Enfermería.

INTRODUCTION

Pressure injuries (PIs) are considered adverse events related to health assistance and represent a significant health problem worldwide with high hospital costs, prolonged hospitalization times and increased morbidity and mortality, in addition to the emotional impact and distress on the patient, these latter perceived as intangible costs¹.

PI can be defined as localized damage to the skin and/or underlying soft tissues, resulting from intense and/or prolonged pressure in combination with shear or related to a medical device or another artifact, usually located over a bony prominence. They are classified as grade one, two, three, four or unclassifiable, according to involvement of the tissues which can present as intact skin or an open ulcer².

The incidence of PI is highly variable across health units in general and, especially in emergency services, the studies point to increasing incidence levels³-⁴. The care volume and complexity in these units increase proportionally to the rise of urban violence in the country and to population aging⁵.

There are several aggravating factors for PI development in patients entering the emergency services; a number of extrinsic factors can be mentioned, such as overcrowding, that increase the waiting time for care and referral, lack of beds, direct and prolonged contact with rigid surfaces such as stretchers, board, splints and cervical collar, and intrinsic factors such as advanced age, previous comorbidities and the patient’s clinical complexity³.

The high demand of patients, the reduction in investment in human resources, the consequent overloading of the team⁶, and the focus on stabilizing the clinical condition make Nursing practices such as assessing the risk of developing PI be postponed or directed exclusively to the high-risk group⁷-⁸.

Given the care complexity faced daily by the Nursing team in emergency rooms (ERs), the importance of classifying the patients’ dependence degree stands out as a subsidy for adequate sizing of the team, providing individualized care and minimizing or preventing harms resulting from the assistance provided⁹.

In this perspective, the Federal Council of Nursing (Conselho Federal de Enfermagem, COFEN) establishes official parameters for the sizing of Nursing personnel through the use of the Patient Classification System (PCS). The classification tool proposed by Perroca¹⁰ stands out among the instruments referenced for this purpose.

The Perroca Classification Instrument (PCI) resorts to a scale that assesses nine areas scoring from one to four. Each area is scored and added to the others, and its results indicate the increasing intensity of care complexity, with the score intervals established as follows: minimal care (8-11 points); intermediate care (12-18 points); semi-intensive care (19-25 points); and intensive care (26-32 points)¹¹.

The patients can present different care complexity degrees in the same hospitalization unit. In this sense, classification of the patients and the subsequent identification of the assistance profile are a fundamental strategy for resource allocation, for staffing, and for strategies that aim at a more adequate care planning and, consequently, the reduction of adverse events, with PIs among them⁹.

The objective of this study is to assess pressure injury development and its association with care complexity in patients treated at an emergency service.

RESULTS

The sample consisted of 225 patients, with predominance of the male gender 147 (65.3%), brown race/skin color 144 (64%) and age group over 60 years old 116 (51.5%). Of these, 136 (60.4%) were hypertensive, 64 (28.4%) were diabetic and 144 (64%) were under continuous medication use. The main medical diagnoses corresponded to diseases of the circulatory system with 76 (36.8%) and to external causes with 31 (13.8%). Most of the participants 139 (61.8%) had impaired physical mobility and 114 (50.7%) used diapers. In relation to the risk classification according to the Braden Scale, 95 (42.2%) presented low risk, 74 (32.9%) moderate risk, 51 (22.2%) high risk, and 5 (2.2%) were not at risk. The main outcome was hospital discharge 117 (52%), followed by transfer 97 (43.1%) and death 11 (4.95%).

In this study, the incidence of PI was 9.3%. The data referring to the patients who developed PIs show that incidence was mostly in women 13 (61.9%), aged at least 80 years old 10 (47.6%), with impaired physical mobility 19 (90.48%), and diaper use 20 (95.2%). In relation to the Braden Scale, high risk was the most observed with 15 (71.43%) cases, and the main outcome was transfer to another unit in 16 (76.2%) patients (Table 1).

Table 1
Characterization of the patients that developed pressure injuries in the emergency service of the General Hospital of Vitória da Conquista, Bahia, Brazil, 2020

Variables	n	%
Gender
Male	8	38.1
Female	13	61.9
Age
Less than 60 years old	5	23.8
60-79 years old	6	28.6
80+ years	10	47.6
Race/Skin color
White	3	14.3
Black	4	19
Brown	14	66.7
Systemic Arterial Hypertension
Yes	15	71.4
No	6	28.6
Diabetes Mellitus
Yes	6	28.6
No	15	71.4
Diagnostic classification
Diseases of the circulatory system	8	38.1
Diseases of the digestive system	5	23.8
*Other diagnoses	8	38.1
Use of diapers
Yes	20	95.2
No	1	4.8
Impaired physical mobility
Yes	19	90.48
No	2	9.52
Difficulty communicating
Yes	10	47.6
No	11	52.4
Continuous medication use
Yes	16	76.2
No	5	23.8
Braden Scale
Low risk	1	4.76
Moderate risk	5	23.81
High risk	15	71.43
Outcome
Transfer	16	76.2
High	4	19
Death	1	4.8

• ^*
  External causes of morbidity and mortality; Diseases of the genitourinary system; Diseases of the respiratory system; Neoplasms; Diseases of the musculoskeletal system.
Source: The authors (2020).

Concerning care complexity, as evaluated by the Perroca Classification Instrument, 75 (33.3%) patients were classified as minimal care, 126 (56%) as intermediate care, and 24 (10.7%) as semi-intensive care with no records of patients in intensive care at the time of the evaluations. The distribution of PI incidence as per PCI was 12 (57.1%) in intermediate care and nine (42.9%) in semi-intensive care, with an association between care complexity and pressure injury incidence with p-value<0.001.

Among all 21 patients who developed PIs, 30 pressure injuries were recorded: 10 (33.4%) in the heels and 9 (30%) in the sacral region. Most of the injuries were staged in grades I and II: 19 (63.3%).

There was no association between the number of PIs and the staging of the injuries or the patients’ care complexity (Table 2).

Table 2
Association between the number of PIs, staging and care complexity in the emergency service of the General Hospital of Vitória da Conquista, Bahia, Brazil, 2020

Variable	InC n (%)	SIC n (%)	Total	p
Number of PIs per patient				0.604
One injury	8 (66.7)	4 (33.3)	12 (57.1)
Two or more injuries	5 (55.6)	4 (44.4)	9 (42.9)
Staging of the injury				0.055
Grades 1 and 2	12 (63.2)	7 (36.8)	19 (57.1)
Grade 3 and unclassifiable	-	2 (100)	2 (42.9)

Reference: InC-Intermediate Care; SIC-Semi-Intensive CareSource: The authors (2020).

METHOD

This is a prospective cohort study of and observational nature and with quantitative approach carried out in an Emergency Unit of a public hospital in the Southwest of Bahia, considered a macroregional reference for high and medium complexity, currently a reference for COVID-19 cases and exclusively serving patients referred by state regulation.

The study was carried out in the Women’s and Men’s Wards, which receive patients who enter the hospital’s emergency service every day for treatments of various etiologies and remain under follow-up in these sectors, awaiting referral to inpatient units or Intensive Care Units (ICUs), with the possibility of presenting other outcomes such as discharge or death.

Data collection was conducted for 60 consecutive days between August and October 2020. The inclusion criteria were as follows: not presenting any PI at admission to the units under study and being aged at least 18 years old. The patients excluded were those that were discharged from the units before 48 hours from having been included in the research.

The instrument used for data collection was adapted from previous studies¹²-¹³ and consists of two stages: the first, to be applied within the first 24 hours since the patient’s admission to the units, contains sociodemographic information, clinical characteristics, the Perroca Classification Instrument (PCI) and the Braden scale, adapted for Brazil by Paranhos and Santos in 1999¹⁴.

The second stage consists in the subsequent reevaluations performed every 48 hours with application of the Braden and PCI scales, observation of the adoption of measures recommended for PI prevention, such as decubitus change, support structures, keeping the sheets taut and the skin moisturized and sanitized, and inspection of the skin, where, in the presence of PI, data such as the staging and anatomical location of the injury are collected. The instrument was evaluated by three nurses with experience in the emergency service and was submitted to a pre-test to verify its applicability.

The data were incorporated to an electronic Microsoft Excel 2010® spreadsheet. The dichotomous variables were coded as “one-yes” and “two-no” and the others were categorized with Arabic numerals. Subsequently, the data were transferred for analysis to the Statistical Package for the Social Sciences® (SPSS) software, version 23 for Windows®. All the sociodemographic information and the clinical characteristics were submitted to descriptive statistical analysis.

The association analysis between PI development and care complexity was verified by means of Pearson’s chi-square test, adopting p-value<0.05 and a 95% confidence interval. There was recategorization of the staging and number of injuries developed and, with the grouping of grades one and two and grades three and four, the number of injuries was recategorized into one injury and two or more injuries.

The study was submitted to the Research Ethics Committee (Comitê de Ética em Pesquisa, CEP) of Universidade Federal da Bahia (CEP-IMS-CAT-UFBA) and was approved under opinion No. 4,122,093.

DISCUSSION

The PI incidence found in this research was lower to the values detected in critical care and medical clinic units of the same institution, where 47% and 24% incidence was identified, respectively¹²-¹³. On the other hand, the result found was higher than in a study conducted in the Emergency Department of a French hospital, with 4.9% incidence⁴.

The studies addressing PI incidence in emergency services are still incipient, as well as analyzing the relationship between incidence of pressure injures and care complexity measured by means of classification instruments. It is worth noting the importance of encouraging studies that address the theme focused on early prevention and on patient safety in general terms¹⁵.

PIs stand out among the indicators of the quality of the assistance provided to the patients, and their incidence is closely related to Nursing care. PIs impose various negative consequences on individuals, families, institutions and the society in general. Their development leads to physical and psychological distress in the patients, in addition to extending the hospitalization time, worsening the clinical condition, and even leading to death¹⁵.

The predominance of males among the research participants can be explained by their low demand in terms of prevention services, leading to future complications such as stroke¹⁶, as well as by being the largest population segment involving external causes such as traffic accidents and assaults¹⁷, allied to the fact that the hospital unit researched is a reference for trauma care.

Despite not being a majority in the sample, women were the most affected by PI development. A number of studies show that women present higher life expectancy than men, which makes them a population group frequently present in hospital units. This profile consists mainly in women over 80 years old with a gradual increase of functional disability that hinder self-care, requiring more assistance from the family and health professionals¹⁸-¹⁹.

The predominance of older adults in the sample, and especially among the patients who developed PI, can be justified by the growth of the aged population and, consequently, by changes in the health profile with the increase of chronic degenerative diseases of low lethality but high disability⁴ which, associated with nutritional status, previous comorbidities, capillary fragility and cognitive deficit, contribute to PI development in the hospital environment²⁰.

Diseases of the circulatory system were the most frequent medical diagnoses and are consistent with the patients’ greater dependence on the Nursing team with emphasis on cerebrovascular diseases¹⁹. Neurological deficit can affect sensory perception and decrease physical mobility and sphincter control, in addition to loss of sensation on body surfaces which, associated with moisture, friction and pressure, can lead to the development of injuries²¹.

A significant percentage of the patients reported being hypertensive and, to a lesser extent, diabetic; such comorbidities contribute to an increase in the cardiovascular risk, in addition to favoring continuous medication use. Systemic Arterial Hypertension (SAH) favors a reduction in the blood vessels’ strength, as well as in blood flow and in vascular tone. As it leads to a reduction in bloodstream and in tissue oxygenation, Diabetes Mellitus (DM) causes cell death due to lack of glucose, decreasing sensitivity and favoring PI formation²¹.

The injuries were mainly located in the heels and in the sacral region and presented stages one and two, results that are similar to those found in other studies that addressed the same theme⁴,²². Location of the injury can be associated with the patient staying in dorsal decubitus for a longer period of time and with elevation of the headboard, concentrating greater pressure on the sacral region and heels⁴,²⁰,²³. In turn, staging can be associated with initial identification of the injury and with the adoption of protective and curative measures, avoiding its deterioration, as well as with the shorter time spent in emergency units when compared to sectors such as clinics and intensive care units.

In relation to care complexity, the patients that developed injuries were classified as Intermediate care and as Semi-intensive care, showing an association between the care level and PI incidence. Patients in more severe conditions have a significantly increased risk of developing PIs due to a complex interaction process between intrinsic and extrinsic factors related to their clinical conditions²³.

There was no association between the number and staging of the injuries and care complexity, although it is worth mentioning that the Nursing team should systematically assess the risk of developing PI, implement preventive measures early in time and, in the occurrence of injury, seek to minimize the deterioration and complications resulting from it.

The dependence degree and the estimated time for each procedure are important indicators of care and human resources management, as overcrowding in emergency services and an inadequate number of professionals interfere with care management and quality, increasing the risk of potentially preventable adverse events such as PIs⁹.

Although it was not the main scale evaluated in this study, the Braden scale proved to be an important and effective tool to predict the risk²⁴. However, with overcrowding in emergency services, it is common in the everyday practice to find low applicability of patient safety assessment scales, with prioritization of administrative activities or measures to stabilize the clinical condition⁷-⁸.

Most of the patients that developed PIs in the emergency service were transferred to other units, which can lead to the development of new injuries or to progression of the already existing ones. In a study about PIs conducted in an intensive treatment unit, it was observed that many of the patients with PIs already had them at admission¹.

The importance of multiprofessional work to the detriment of vertical and isolated measures focused on the disease is highlighted. Commitment should be focused on preventing development of injuries from the moment the patient enters the emergency room and be perpetuated throughout the hospitalization period with development of access protocols and continuous training of health care teams²³.

The main limitations of this study lie in the changes in the routine to admit patients in the men’s and women’s wards and in the study field during the data collection period. Due to the pandemic, on some occasions the wards were isolated due to the presence of patients with suspected coronavirus infection, which limited admission of other patients to the units, who remained for a longer period of time in the emergency department corridor and, when transferred to the wards, some had already developed PIs and were excluded from the study. These limitations may have contributed to underestimating the incidence of pressure injuries in the emergency service.

CONCLUSION

The incidence of pressure injury in the emergency service identified in this study was 9.3%. Most of the patients that developed PIs corresponded to aged women, brown race/skin color, hypertensive, with impaired physical mobility and in use of diapers. There was an association between care complexity and PI incidence. A total of 30 injuries were recorded, predominantly located in the sacral region and in the heels, and with staging in grades one and two.

There are also contributions to the practice, as the study highlights the importance of using instruments for risk assessment and care demands of patients entering the emergency services, whose data at admission can contribute to improving care quality, to reducing the occurrence of adverse events and to providing safe care.

REFERÊNCIAS

• ¹
  Petz F de FC, Crozeta K, Meier MJ, Lenhani BE, Kalinke LP, Pott FS. Úlcera por pressão em unidade de terapia intensiva: estudo epidemiológico. Rev enferm UFPE on line. [Internet]. 2017. [acesso em 11 jan 2021];11(1)287-93. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/viewFile/11907/14388
  » https://periodicos.ufpe.br/revistas/revistaenfermagem/article/viewFile/11907/14388
• ²
  National Pressure Ulcer Advisory Panel (NPUAP). Pressure Ulcer Stages Revised. [Internet]. 2016. [acesso em 11 jan 2021]. Disponível em: http://www.npuap.org/resources/educational-and-clinical-resources/pressure-injury-staging-illustrations/
  » http://www.npuap.org/resources/educational-and-clinical-resources/pressure-injury-staging-illustrations/
• ³
  Liu P, Shen WQ, Chen HL. The incidence of pressure ulcers in the emergency department: a metaanalysis. Wounds: a Compendium of Clinical Research and Practice. [Internet]. 2016. [acesso em 11 jan 2021]; 29(1):14-19. Disponível em: https://europepmc.org/article/med/27852014
  » https://europepmc.org/article/med/27852014
• ⁴
  Dugaret E, Videau M-N, Faure I, Gabinski C, Bourdel-Marchasson I, Salles N. Prevalence and incidence rates of pressure ulcers in an Emergency Department. Int Wound J. [Internet]. 2014. [acesso em 11 jan 2021]; 11(4):386-91. Disponível em: https://doi.org/10.1111/j.1742-481X.2012.01103.x
  » https://doi.org/10.1111/j.1742-481X.2012.01103.x
• ⁵
  Paixão DP da SS da, Batista J, Maziero ECS, Alpendre FT, Amaya MR, Cruz ED de A. Adhesion to patient safety protocols in emergency care units. Rev Bras Enferm. [Internet]. 2018. [acesso em 11 jan 2021]; 71(suppl 1):577-84. Disponível em: https://doi.org/10.1590/0034-7167-2017-0504
  » https://doi.org/10.1590/0034-7167-2017-0504
• ⁶
  Amaral APS, Longuiniere ACF de la, Santos JNM de O, Vilela ABA, Vieira SNS, Sanches G de JC. Occupational stress: the exposure of an emergency unit nursing team. Estresse ocupacional: exposição da equipe de enfermagem de uma unidade de emergência. Rev Pesqui Cuid É Fundam Online. [Internet]. 2019. [acesso em 11 jan 2021];11(2): 455-463. Disponível em: http://dx.doi.org/10.9789/2175-5361.2019.v11i2.455-463
  » http://dx.doi.org/10.9789/2175-5361.2019.v11i2.455-463
• ⁷
  Padula WV, Pronovost PJ, Makic MBF, Wald HL, Moran D, Mishra MK, et al. Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis. BMJ Qual Saf. [Internet]. 2019. [acesso em 11 jan 2021]; 28(2):132-41. Disponível em: http://dx.doi.org/10.1136/bmjqs-2017-007505
  » http://dx.doi.org/10.1136/bmjqs-2017-007505
• ⁸
  Naccarato MK, Kelechi T. Pressure ulcer prevention in the emergency department. Adv Emerg Nurs J. [Internet]. 2011. [acesso em 11 jan 2021]; 33(2):155-62. Disponível em: http://doi.org/10.1097/TME.0b013e3182157743
  » http://doi.org/10.1097/TME.0b013e3182157743
• ⁹
  Souza M da C, Loureiro MDR, Batiston AP. Organizational culture: prevention, treatment, and risk management of pressure injury. Rev Bras Enferm. [Internet]. 2020. [acesso em 16 de jan de 2021]; 73(3). Disponível em: http://dx.doi.org/10.1590/0034-7167-2018-0510
  » http://dx.doi.org/10.1590/0034-7167-2018-0510
• ¹⁰
  Conselho Federal de Enfermagem (COFEN). Resolução n. 543, de 18 de abril de 2017. Atualiza e estabelece o dimensionamento do quadro de profissões de enfermagem. [Internet]. 2017. [Acesso em 10 de janeiro de 2021]. Brasília: COFEN; 2017. Disponível em: http://www.cofen.gov.br/wp-content/uploads/2017/05/RESOLU%C3%87%C3%83O-COFEN-N%C2%BA-543-2017-completa.pdf
  » http://www.cofen.gov.br/wp-content/uploads/2017/05/RESOLU%C3%87%C3%83O-COFEN-N%C2%BA-543-2017-completa.pdf
• ¹¹
  Perroca MG. Desenvolvimento e validação de conteúdo da nova versão de um instrumento para classificação de pacientes. Rev Lat Am Enfermagem. [Internet]. 2011. [acesso em 11 jan 2021]; 19(1):58-66. Disponível em: http://www.Redalyc.org/articulo.oa?id=281421953009
  » http://www.Redalyc.org/articulo.oa?id=281421953009
• ¹²
  Silva SAM da, Pires P da S, Macedo MP, Oliveira LS, Batista JET, Amaral JM. Lesão por pressão: incidência em unidades críticas de um hospital regional. ESTIMA. [Internet]. 2018. [acesso em 11 jan 2021]; 16: [1-10]. Disponível em: https://doi.org/10.30886/estima.v16.655_PT
  » https://doi.org/10.30886/estima.v16.655_PT
• ¹³
  Jesus MAP de, Pires P da S, Biondo CS, Matos RM e. Incidência de lesão por pressão em pacientes internados e fatores de risco associados. Rev. baiana enferm. [Internet]. 2020. [acesso em 11 jan 2021]; 34. Disponível em: http://dx.doi.org/10.18471/rbe.v34.36587
  » http://dx.doi.org/10.18471/rbe.v34.36587
• ¹⁴
  Paranhos WY, Santos VLCG. Avaliação de risco para úlcera por pressão pela escala de Braden, em português; Rev. Esc. Enf. USP. [Internet]. 1999. [acesso em 14 de jan de 2021]; 33:191-206. Disponível em: http://www.ee.usp.br/reeusp/upload/pdf/799.pdf
  » http://www.ee.usp.br/reeusp/upload/pdf/799.pdf
• ¹⁵
  Gamston, J. Pressure induced skin and soft tissue injury in the emergency department. Emerg. med. j. [Internet]. 2019. [acesso em 08 de ago de 2022]; 36(10). Disponível em: https://emj.bmj.com/content/36/10/631
  » https://emj.bmj.com/content/36/10/631
• ¹⁶
  Ferro D, Fabriz LA, Schönholzer TE, Viola CG, Valente SH, Zacharias FCM, et al Sociodemographic and clinical profile of the patient with chronic disease treated at an emergency service. Res., Soc. Dev. [Internet]. 2021. [acesso em 08 de ago de 2022]; 10(7). Disponível em: https://rsdjournal.org/index.php/rsd/article/view/16263
  » https://rsdjournal.org/index.php/rsd/article/view/16263
• ¹⁷
  Marques SHB, Souza AC de, Vaz AA, Pelegrini AHW, Linch GF da C. Mortalidade por causas externas no Brasil de 2004 a 2013. Rev Baiana Saúde Pública. [Internet]. 2018. [acesso em 11 de jan de 2021]; 41(2). Disponível em: http://rbsp.sesab.ba.gov.br/index.php/rbsp/article/view/2368
  » http://rbsp.sesab.ba.gov.br/index.php/rbsp/article/view/2368
• ¹⁸
  Paiva SCL, Gomes CP, Almeida LG de, Dutra RR, Aguiar NP, Lucinda MF, et al A Influência das comorbidades, do uso de medicamentos e da institucionalização na capacidade funcional dos idosos. Rev. interdisciplin. estud. exp. anim. hum. [Internet]. 2014. [acesso em 11 de jan de 2021]; 6: 46-53. Disponível em: https://periodicos.ufjf.br/index.php/riee/article/view/24009
  » https://periodicos.ufjf.br/index.php/riee/article/view/24009
• ¹⁹
  Lage JSS, Okuno MFP, Campanharo CRV, Lopes MCBT, Batista REA. Functional capacity and profile of elderly people at emergency units. REME Rev Min Enferm. [Internet]. 2014. [acesso em 16 de jan de 2021];18(4). Disponível em: http://www.gnresearch.org/doi/10.5935/1415-2762.20140063
  » http://www.gnresearch.org/doi/10.5935/1415-2762.20140063
• ²⁰
  Gamston J. Pressure induced skin and soft tissue injury in the emergency department. Emerg Med J. [Internet]. 2019. [acesso em 16 de jan de 2021]; 36(10):631-4. Disponível em: http://dx.doi.org/10.1136/emermed-2018-207807
  » http://dx.doi.org/10.1136/emermed-2018-207807
• ²¹
  Geovanine TG. Tratado de feridas e curativos. São Paulo: RIDEEL; 2014.
• ²²
  Arenas EB, Castañeda MDCP, Jiménez GP, Jiménez PH, Rodríguez JAR, Zárate MPP. Prevalencia de úlceras por presión en un hospital de tercer nivel, en México DF. Gerokomos. [versão impressa]. 2016; 27(4):176-181.
• ²³
  Santamaria N, Creehan S, Fletcher J, Alves P, Gefen A. Preventing pressure injuries in the emergency department: current evidence and practice considerations. Int Wound J. [Internet]. 2019 [acesso em 16 de jan de 2021]; 16(3):746-52. Disponível em: https://doi.org/10.1111/iwj.13092
  » https://doi.org/10.1111/iwj.13092
• ²⁴
  Jansen RCS, Silva KB de A, Moura MES. Braden Scale in pressure ulcer risk assessment. Rev Bras Enferm. [Internet]. 2020. [acesso em 16 de jan de 2021];73(6). Disponível em: http://dx.doi.org/10.1590/0034-7167-2019-0413
  » http://dx.doi.org/10.1590/0034-7167-2019-0413

Edited by

Associate editor: Dra. Luciana Nogueira

Publication Dates

• Publication in this collection
  16 Dec 2022
• Date of issue
  2022

History

• Received
  21 Aug 2021
• Accepted
  10 Aug 2022