1 Nurse at the I ntensive Therapy Unit, Heart I nstitute, Medical School; 2 Est om at herapist nurse, Sc.M. in Nursing, Surgical Nursing Division of t he School Hospital Director; 3 Est om at herapist nurse, Sc.M. in Nursing, Head of t he Surgical Clinical Unit of t he School Hospit al; 4 Nurse, Professor, School of Nursing, Brazil.e- m ail: ffugulim @usp.br. Universit y of São Paulo
Disponible en castellano/ Disponível em língua portuguesa SciELO Brasil w w w .scielo.br/ rlae
PATI ENT CLASSI FI CATI ON SYSTEM: A PROPOSAL TO COMPLEMENT THE I NSTRUMENT BY
FUGULI N ET AL.
Fer nanda dos Sant os1
Noem i Mar isa Br unet Rogensk i2
Cleide Mar ia Caet ano Bapt ist a3
Fer nanda Mar ia Togeir o Fugulin4
Sant os F, Rogenski NMB, Bapt ist a CMC, Fugulin FMT. Pat ient classificat ion syst em : a proposal t o com plem ent t he inst rum ent by Fugulin et al. Rev Lat ino- am Enferm agem 2007 set em bro- out ubro; 15( 5) : 980- 5.
Analysis of pat ient classificat ion inst rum ent s available in t he lit erat ure shows t hat m any significant aspect s related to the assistance to patients with wounds are not approached, evidencing the im portance to elaborate criteria to assess these patients. This study proposes the developm ent of new of areas of care to com plem ent the Fugulin et al. instrum ent, validated by the Federal Nursing Council (COFEN). The construction of new areas to evaluate wounds was based on a bibliographic search on the operational m odels of the Patient Classification System (PCS), as well as on several inst rum ent s of wound classificat ion. New areas of care were est ablished, as follows: t issue im pairm ent , num ber of dressing changes and tim e taken to their preparation. Values were also redefined indicating the patient’s assistance category. The com plem entation of the Fugulin et al. instrum ent, proposed here, favors the application of this instrum ent in a m ore diversified group of patients since it adds a relevant assistance aspect, as the dressing issue.
DESCRI PTORS: per sonnel adm inist r at ion; hospit al; nur sing; t eam ; t im e m anagem ent ; w ound healing
SI STEMA DE CLASI FI CACI ÓN DE PACI ENTES: PROPUESTA DE COMPLEMENTACI ÓN DEL
I NSTRUMENTO FUGULI N ET AL.
El análisis de los inst rum ent os de clasificación de pacient es, disponibles en la lit erat ura, dem uest ra que aspect os relevant es de la at ención a pacient es port adores de herida dej an de ser discut idos, dej ando evident e la im port ancia de elaborar crit erios que posibilit en evaluar est os pacient es. Est e est udio propone la elaboración de cr it er ios que posibilit en ev aluar est os pacient es, y t am bién la elabor ación de ár eas de cuidados de m aner a a com plem ent ar el inst rum ent o de Fugulin et al., validado por el Consej o Federal de Enferm ería ( COFEN) , que no cont em pla est e aspect o. La const rucción de las áreas de cuidados para evaluación de heridas se fundam ent ó en un levant am ient o bibliográfico sobre los m odelos operacionales del Sist em a de Clasificación de Pacient es ( SCP) , bien com o sobre los dist int os inst rum ent os de clasificación de heridas. Fueron configuradas com o nuevas áreas de cuidado: el com pr om et im ient o del t ej ido, el núm er o de cam bios del cur at iv o y el t iem po ut ilizado par a su realización. Aún fueron redefinidos los valores que indican la cat egoría asist encial del pacient e. La com plem ent ación del inst rum ent o Fugulin et al., propuest a en est e est udio, favorece la aplicación del inst rum ent o a un grupo m ás diversificado, por agregar un aspect o relevant e de at ención que es la cuest ión de los curat ivos.
DESCRI PTORES: adm inist r ación de per sonal en hospit ales; gr upo de enfer m er ía; adm inist r ación del t iem po; cicat r ización de h er idas
SI STEMA DE CLASSI FI CAÇÃO DE PACI ENTES: PROPOSTA DE COMPLEMENTAÇÃO DO
I NSTRUMENTO DE FUGULI N ET AL.
A análise dos instrum entos de classificação de pacientes, disponíveis na literatura, dem onstra que aspectos relevantes da assistência a pacientes portadores de feridas deixam de ser abordados, ficando evidente a im portância da elaboração de crit érios que possibilit em avaliar esses pacient es. Est e est udo propõe a elaboração de áreas de cuidados de form a que com plem ente o instrum ento de Fugulin et al., referendado pelo Conselho Federal de Enferm agem ( COFEN) do Brasil, que não contem pla esse aspecto. A construção das áreas de cuidados para avaliação de feridas fundam ent ou- se em busca bibliográfica acerca de m odelos operacionais de Sist em a de Classificação de Pacient es ( SCP) , bem com o sobre os diversos instrum entos de classificação de feridas. Configuraram - se com o novas áreas de cuidado: o com prom et im ent o t ecidual, o núm ero de t rocas do curat ivo e o t em po ut ilizado para a sua realização. Foram redefinidos, ainda, os valores que indicam a categoria assistencial do paciente. A com plem entação do instrum ento de Fugulin et al., propost a nest e est udo, favorece a aplicação do inst rum ent o a um grupo m ais diversificado de pacient es por acrescer aspect o relevant e da assist ência, com o a quest ão dos curat ivos.
I NTRODUCTI ON
P
at ient s’ classificat ion in accor dance w it h t h eir lev el of depen den ce on t h e n u r sin g t eam is o n e o f t h e st ep s i n st af f d i m en si o n i n g m et h o d s w hich, due t o it s im plicat ions, has becom e a sour ce o f c o n s t a n t c o n c e r n , d i s c u s s i o n a n d r e s e a r c h am o n g n u r ses, w h o ar e i n t er est ed i n p r o d u ci n g h ig h - q u alit y ser v ices w it h a v iew t o at t en d in g t o clien t s’ n eed s.Gaid zin sk i’s( 1 ) n u r sin g st af f d im en sion in g
m et hod indicat es t he ident ificat ion of t he follow ing v ar iables for it s applicat ion: w or k load at t he unit ; t echnical secur it y r at io and act ual w or k t im e. The work load of t he nursing care unit is t he product of t h e m e a n d a i l y q u a n t i t y o f a t t e n d e d p a t i e n t s, accor d in g t o t h eir d eg r ee of d ep en d en ce on t h e nursing t eam , and t he m ean nursing care t im e used per pat ien t , accor din g t o t h e pr esen t ed degr ee of dependence( 2 ).
I n or der t o iden t if y t h e m ean qu an t it y of a t t en d ed p a t i en t s, a cco r d i n g t o t h ei r d eg r ee o f dependence on the nursing team , patients need to be classified in t erm s of t heir dependence on t his t eam , using one of t he Pat ient Classificat ion Syst em s ( PCS) available in lit erat ure which best at t ends t he client s’ char act er ist ics.
Th e PCS can b e u n d er st ood as a w ay of det erm ining a pat ient ’s degree of dependence on t he nur sing t eam , w it h a v iew t o est ablishing t he t im e spent on direct and indirect care, as well as the num ber of st aff t o at t end t o t he pat ient ’s bio- psycho- social-spirit ual needs( 3).
Co n s i d e r e d a n e s s e n t i a l i n s t r u m e n t i n n u r s i n g m a n a g e m e n t p r a c t i c e , t h e PCS a l s o p r o v i d es i n f o r m a t i o n f o r d eci si o n - m a k i n g a b o u t hum an resource allocat ion, product ivit y and nursing ca r e co st m o n i t o r i n g( 4 ), a s w e l l a s f o r se r v i ce
or ganizat ion and nur sing car e planning. Know ledge abou t pat ien t s’ car e pr of ile is an ot h er f act or t h at can support t he planning and im plem ent at ion of care p r o g r am s t h at can b est at t en d t o t h ese cl i en t s’ n eed s, h el p i n g i n d ai l y n u r si n g h u m an r eso u r ce dist r ibut ion and t r aining t o at t end t o each pat ient gr oup( 5).
Despit e t he num ber of pat ient classificat ion in st r u m en t s av ailab le in Br azilian lit er at u r e, it is observed in pract ice t hat nurses are m ore concerned with the elaboration of new than with the applicability of exist ing inst rum ent s.
The m ain m otives appointed for this fact refer t o t he allegat ion t hat pat ient classificat ion sy st em s a r e i n f l u e n ce d b y o p e r a t i o n a l a sp e ct s, m e d i ca l pr act ices and car e st andar ds char act er ist ic of each inst it ut ion.
Th e Fe d e r a l N u r s i n g Co u n c i l ( COFEN ) , t hr ough Resolut ion No293/ 04( 6), w hich est ablishes
official par am et er s for n u r sin g st aff dim en sion in g, r at ified t he PCS by Fugulin et al.( 7). Based on t his
classif icat ion , t h e COFEN in d icat ed t h e m in im u m n u m b er of car e h ou r s an d , also, t h e p er cen t ag e dist ribut ion of nursing professionals for each t ype of car e.
Thus PCS( 7), developed and im plant ed at t he
Medical Clinic Unit of t he Universit y Hospit al at t he Un i v e r s i t y o f Sã o Pa u l o , w a s a p p l i e d a t t h i s inst it ut ion’s ot her hospit alizat ion unit s, observing t hat i t d o e s n o t f u l l y a t t e n d t o p e d i a t r i c p a t i e n t charact erist ics and does not apply t o infant s. At t he surgical unit s, according t o t he st udy aut hor( 8), t he
nurses indicat ed t hat t hey felt a lack of param et ers t h a t w o u l d m a k e i t p o ssi b l e t o a ssess p a t i en t s’ d if f er en t k in d s of in j u r ies, w h ich in t er f er e in an d det erm ine daily care, at different care levels, at t he m om ent w ound dr essing is per for m ed.
Wou n d car e h as alw ay s b een a sou r ce of g r e a t d i s c u s s i o n a m o n g n u r s e s a n d t h e s e professionals’ concern wit h t he care t o be delivered t o t h ese p at i en t s g oes b ack a l on g w ay. Am on g healt h t eam m em bers, nurses are t he professionals m ost int im at ely involved wit h care delivery t o pat ient s wit h inj uries, and have also direct ed and im plem ent ed t his care in pract ice( 9).
Lit er at ur e pr esent s count less concept s and ways of classifying wounds. Generically, wounds can be defined as a rupture in the body’s norm al anatom ic a n d f u n ct i o n a l st r u ct u r e s, w h i ch l e a d s t o t h e im p air m en t of t h e t issu lar p h y siolog ical f u n ct ion , resulting in a loss of its integrity.
Classify ing w ounds helps t o sy st em at ically r e g i st e r t h e i r ch a r a ct e r i st i cs, p e r m i t s p l a n n i n g t r eat m en t st r at egies, accom pany in g t h eir efficacy, predict ing result s and facilit at ing t he com m unicat ion bet ween t he professionals involved in care( 9).
Th e n e e d t o p e r f o r m e x t e n si v e w o u n d dr essin g can dem an d dir ect car e t im e t h at is n ot com pat ible wit h t he est im at ed t im e for t he pat ient ’s care cat egory, obt ained by applying t he classificat ion inst rum ent s t hat do not cover t he realizat ion of t his procedure, int erfering in t he planning of t he num ber o f st a f f n e e d e d t o a t t e n d t h e p a t i e n t s a n d , consequent ly, in t he qualit y of care delivery.
I n view of t his problem and considering t hat the instrum ent( 7) ratified by the COFEN does not fully
attend to the needs of surgical patients and/ or patients with inj uries, we decided to perform this study, which aim s t o:
OBJECTI VES
Gener al Obj ect iv e
- Com plem ent the patient classification instrum ent by Fu g u l i n e t a l .( 7 ), i n d i ca t i n g p a r a m e t e r s f o r t h e
classificat ion of pat ient s’ different kinds of inj uries.
Specific Obj ect iv es
- Const ruct care areas t hat allow for t he assessm ent of pat ient s’ differ ent k inds of inj ur ies, accor ding t o t he level of dependence on t he nursing t eam . - Attribute weights to each nursing dependence level, relat ed t o t he new proposed care areas.
- Redefine t he sum of t he v alues t hat indicat e t he pat ient s’ care cat egory.
METHOD
Th e con st r u ct ion of car e ar eas f or w ou n d assessm ent w as based on a bibliogr aphic r eview in indexed dat abases ( Dedalus and Medline) , relat ed t o t h e l a st t en y ea r s, u si n g t h e t er m s s i s t e m a d e classif icação de pacien t es and en f er m agem , pat ient and classification and system and nursing, feridas and w ound.
The Dedalus database, m ade available by the Un i v e r si t y o f Sã o Pa u l o ( USP) Li b r a r y Sy st e m , p er m it t ed access t o 1 3 8 b ib liog r ap h ic r ef er en ces through the term feridas and 22 when using the words
s i s t e m a d e c l a s s i f i c a ç ã o d e p a c i e n t e s a n d
enfer m agem. The inst rum ent m ade available by t he
Virt ual Healt h Library ( BVS) , called BI REME, allowed
for t he search in t he Medline dat abase and ident ified 2 4 5 r efer en ces w h en using t he w or ds pat ient and classif icat ion an d sy st em an d n u r sin g an d 2 8 9 9 2 t hrough t he t erm wound. I n view of t he num ber of r e f e r e n ce s f o u n d t h r o u g h t h e t e r m w o u n d , t h e research was refined in t he Medline dat abase, using t h e w or ds w ou n d an d classificat ion , w h ose sear ch result ed in t he ident ificat ion of 363 references.
The obt ained bibliogr aphic r efer ences w er e selected by m eans of the title. Of the references found in Dedalus, thirteen were analyzed, related to the term
f e r i d a s an d six r elat ed t o t h e w or d s si st e m a d e
c l a s s i f i c a ç ã o d e p a c i e n t e s a n d e n f e r m a g e m. I n Me d l i n e , 2 1 r e f e r e n ce s w e r e a n a l y ze d o f t h o se obt ained by using t he t erm w ound and classificat ion
and 23 of those identified by using the words patient and classificat ion and syst em and nursing.
Th e b i b l i o g r a p h i c r e f e r e n ce s t h a t w e r e analyzed m ade it possible to identify, select and assess t h e op er at ion al PCS m od els( 5 , 7 , 1 0 ), as w ell as t h e
assessm ent instrum ents and wound classifications that ar e cu r r en t ly u sed in h ospit al pr act ice. Af t er t h is assessm ent , t he aim was t o elaborat e t he new care areas, t o describe t he different levels of dependence on t he nursing t eam pat ient s could present in each ar ea an d t o r edef in e t h e v alu es t h at in dicat e t h e pat ient ’s care cat egory in t he inst rum ent by Fugulin et al.( 7).
To pr opose t h e n ew car e ar eas, t h e m ain asp ect s w er e ch osen t h at ar e con sid er ed in car e delivery to patients with inj uries, attributing four care dependence or com plex it y sit uat ions t o each ar ea, which were ranked from one to four, so as to represent t he incr easing com plex it y of car e and t he r equir ed nursing care t im e.
RESULTS
Am o n g t h e a sp e ct s co n si d e r e d i n ca r e delivery t o pat ient s wit h inj uries, which can int erfere in car e com plex it y and nur sing car e t im e planning, t h e f o l l o w i n g w e r e ch o se n : t i ssu e i m p a i r m e n t , fr equency of and t im e r equir ed for w ound dr essing wit hin 24 hours.
Tissue im pair m ent
t i ssu e l ay er s an d g r an t s g r eat er o b j ect i v i t y an d unifor m it y t o t he infor m at ion obt ained t hr ough it s assessm en t .
Sim ilarly t o ot her kinds of inj uries, pressure ulcers can be classified and assessed in different ways. However, in 1989, the National Pressure Ulcer Advisory Panel ( NPUAP) est ablished a st aging based on t issue im pairm ent , which t he Agency for Healt h Care Policy an d Resear ch ( AHCPR) r ecom m en d ed in 1 9 9 2 t o ident ify and classify t hese inj uries, which perm it t ed uniform inform at ion for universal use( 16).
Alt h ou gh dir ect ed at pr essu r e u lcer s, t h is classification by the NPUAP( 11- 12) can be applied to other
t y p e s o f i n j u r i e s. Th u s, i n t h i s r e se a r ch , t h i s classification was chosen to construct the indicator, in co m b i n a t i o n w i t h ch a r a ct e r i st i cs t h a t w e r e n o t addressed in the classification proposed by the NPUAP, su ch a s t h e p r esen ce o f d r a i n s o r o st o m i es f o r ex am p le.
The care area was defined as follows
- Cut aneous- m ucous int egrit y/ t issue im pairm ent
1. I nt act skin.
2 . Pr e se n ce o f sk i n co l o r a l t e r a t i o n ( b r u i se , hyperem ia) and/ or presence of cont inuit y solut ion in t he skin, involving t he epiderm is, derm is or bot h. 3. Presence of continuity solution in the skin, involving subcut aneous t issue and m uscle. Sur gical incision. Ost om ies. Dr ains.
4. Pr esence of cont inuit y solut ion in t he sk in w it h dest r uct ion of t he der m is, epider m is, m uscles and im pairm ent of ot her skin st ruct ures, such as t endons and capsules. Eviscerat ions.
Frequency of dressing changes
The m ain obj ect ive of a dressing is t o favor t h e scar r in g p r ocess. Th u s, t h e ch oice of t op ical therapy for wound treatm ent m ust be based on clinical wound charact erist ics and on t he scarring phase t he wound has reached( 17).
Likewise, t he periodicit y of dressing changes m ust be based on t he quant it y and charact erist ics of t he ex udat e pr esent in t he w ound bed and on t he t ype of dressing used for it s t reat m ent .
Som e dressings can be changed every t hree or five days. Others can rem ain on the wound bed for up t o seven days. However, sim ple dressings, which ar e p r ed o m i n an t i n a l ar g e m aj o r i t y o f h o sp i t al
institutions, needs to be changed at least once a day, due t o t he charact erist ic it self of t he m at erial t hat is u sed.
Sim ple dressings ( gauze and adhesive t ape) h av e a lim it ed ab sor p t ion cap acit y. Th e ex u d at e su r p l u s ca n r e t a r d ce l l g r o w t h a n d p r o l o n g t h e i n f l a m m a t o r y p h a s e , t u r n i n g t h e f o r m a t i o n o f gr anulat ion t issue m or e difficult , besides incr easing t h e r i sk o f a l t e r a t i o n s i n sk i n PH, f a v o r i n g t h e ir r it at ion an d m acer at ion of t h e per i- in j u r ed sk in . Th e r e f o r e , c o n s i d e r i n g t h e a b o v e d e s c r i b e d a sp e ct s, t h e n u m b e r o f d r e ssi n g ch a n g e s w a s associat ed w it h t h e p at ien t ’s g r eat er d ep en d en ce on t he nur sing t eam , pr oposing t he follow ing car e a r e a :
- Dr essings
1. Pat ient does not perform dressing or cleaning of t he wound/ surgical incision during bat hing;
2 . Dr essin g per for m ed on ce a day by t h e n u r sin g t eam ;
3. Dressing perform ed 2 tim es per day by the nursing t eam ;
4. Dressing perform ed m ore than 3 tim es per day by t he nursing t eam .
Tim e used for wound dressing
The t im e used for wound dressing is closely r elat ed w it h t he inj ur y’s degr ee of im pair m ent , t he pr ofessional’s abilit y t o per for m t he t echnique and t he react ion or collaborat ion of t he pat ient subm it t ed t o t he procedure( 18).
The tim e intervals established in this care area w er e det er m ined em pir ically, based on ex per ien ce and on the tim e spent to apply the dressings.
- Mean t im e used for wound dressing
1. No dressing.
2. Between 5 and 15 m inutes. 3. Between 15 and 30 m inutes. 4. More than 30 m inutes.
The final proposal t o com plem ent t he pat ient classif icat ion in st r u m en t( 7 ) is r epr esen t ed in Table
Table 1 - Patient classification instrum ent by Fugulin et al.( 7), com plem ented with care areas to assess patients
wit h inj uries. São Paulo, SP, 2006
Th e su m o f t h e v al u es t h at i n d i cat e t h e pat ient s’ care cat egory was redefined as follows:
Table 2 - Score corresponding t o t he care cat egories defined by Fugulin et al.(7), obtained through the application
of the instrument complemented with care areas to assess patients with injuries. São Paulo, SP, 2006
CONCLUSI ON
This st udy allowed for t he ident ificat ion and p r op osit ion of n ew car e ar eas, w h ich r ef lect t h e
ch a r a ct e r i st i cs o f p a t i e n t s w i t h i n j u r i e s, com plem ent ing t he pat ient classificat ion inst r um ent by Fugulin et al.( 7).
This proposal m akes it possible t o apply t he inst r um ent t o a m or e div er sified gr oup of pat ient s, because it adds a r elev ant aspect of car e, such as dr essings.
Th e f o cu s i s n o t t o t e st o r m o n i t o r t h e r eliab ilit y or v alid it y of t h e in st r u m en t( 7 ), b u t t o
com plem ent it and cont ribut e in som e way t o revert t he cur r ent scenar io, m ainly at sur gical unit s, w it h r espect t o t h e av ailabilit y of pat ien t classif icat ion inst r um ent s t hat cont em plat e t he char act er ist ics of their clientele. Future research will test the instrum ent a n d a p p l y i t a s a m a n a g e m e n t t o o l ca p a b l e o f support ing t he dim ensioning and allocat ion of hum an resources at t hese unit s.
REFERENCES
1 . Ga i d z i n s k i RR. D i m e n s i o n a m e n t o d e p e s s o a l d e enfer m agem em inst it uições hospit alar es. [ t ese] . São Paulo ( SP) : Escola d e En f er m ag em / USP; 1 9 9 8 .
2 . Ga i d z i n s k i RR, Fu g u l i n FM T, Ca s t i l h o V. D i m e n s i o n a m e n t o d e p e s s o a l d e e n f e r m a g e m e m i n st i t u i çõ e s d e sa ú d e . I n : Ku r cg a n t P, co o r d e n a d o r a . Ge r e n ci a m e n t o e m e n f e r m a g e m . Ri o d e Ja n e i r o ( RJ) : Gu an ab ar a Koog an ; 2 0 0 5 . p . 1 2 5 - 3 7 .
3 . Ga i d z i n sk i RR. O d i m e n si o n a m e n t o d o p e sso a l d e en f er m a g em seg u n d o a p er cep çã o d e en f er m ei r a s q u e v iv enciam est a pr át ica. [ t ese] . São Paulo ( SP) : Escola de En f er m ag em / USP; 1 9 9 4 .
4 . De Gr oot HÁ. Pat ien t classificat ion sy st em ev alu at ion . Par t 2: Sy st em select ion im plem ent at ion. J Nur s Adm 1989 Ju l y - Au g u st ; 1 9 ( 7 ) : 2 4 - 3 0 .
5 . Fu g u l i n FMT, Gai d zi n sk i RR, Ku r cg an t P. Si st em a d e classificação de pacient es: ident ificação do perfil assist encial dos pacient es das unidades de int er nação do HU- USP. Rev Lat ino- am Enferm agem 2005 j aneiro- fevereiro; 13( 1) : 72- 8.
a e r A e r a
C Carecomplextiyranking
4 3 2 1
e t a t S l a t n e
M Unconscious. Peirodsofunconsciousness. Peirodsofdisoirentaitoninitme . e c a p s d n a . e c a p s d n a e m it n i n o it a t n e ir O n o it a n e g y x
O Mechanicalventliaiton(useof .) r o t a li t n e v e m u l o v r o e r u s s e r p n e g y x o r o k s a m f o e s u s u o u n it n o C .r e t e h t a c n e g y x o r o k s a m f o e s u t n e tt i m r e t n I .r e t e h t a c . n e g y x o n o g n i d n e p e d t o N s n g i S l a ti
V Conrtolinintervalsoftwohoursor . s s e l . s l a v r e t n i r u o h -r u o f n i l o rt n o
C Conrtolinsix-hourintervals. Rouitneconrtol(eighthours.)
y ti li t o
M Incapableofmovinganybody .t n e m g e s . s t n e m g e s y d o b e v o m o t y tl u c if fi D e v i s s a p d n a s u ti b u c e d n i e g n a h C . g n i s r u n y b d e p l e h s t n e m e v o m . s t n e m e v o m d e ti m i
L Movesallbodysegments.
e v i s s a p d n a s u ti b u c e d n i e g n a h C d n a d e m m a r g o r p s t n e m e v o m . g n i s r u n y b d e m r o fr e p g n i k l a
W Restirctedtobed. Locomoitonusingawheelchai.r Needshelptowalk. Walking. g n i d e e
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6. Conselho Regional de Enferm agem [ Página na int ernet ] . São Paulo: Conselho Feder al de Enfer m agem ; [ Acesso em 2004 novem bro 14] . Resolução nº 293/ 04. Fixa e est abelece parâm et ros para dim ensionam ent o do quadro de profissionais de enfer m agem nas inst it uições de saúde. Disponív el em : ht t p: / / w w w .cor ensp.or g.br / r esolucao293.ht m
7 . Fu g u l i n FMT, Si l v a SH S, Sh i m i zu H E, Ca m p o s FPF. I m plant ação do Sist em a de Classificação de pacient es na u n i d ad e d e Cl ín i ca m éd i ca d o Hosp i t al Un i v er si t ár i o d a Universidade de São Paulo. Rev Med HU- USP 1994; 4( 1/ 2) : 6 3 - 8 .
8. Fugulin FMT. Dim ensionam ent o de pessoal de enferm agem : avaliação do quadro de pessoal das unidades de int ernação de um hospit al de ensino. [ t ese] . São Paulo ( SP) : Escola de Enfer m agem / USP; 2 0 0 2 .
9. Polet t i NAA. O cuidado de enferm agem a pacient es com f er id as cr ôn icas: a b u sca d e ev id ên cias p ar a a p r át ica. [ dissert ação] . Ribeirão Pret o ( SP) : Escola de Enferm agem de Ribeir ão Pr et o/ USP; 2 0 0 0 .
1 0 . Per r o ca MG. Si st em a d e cl assi f i cação d e p aci en t e: const rução e validação de um inst rum ent o. [ t ese] . São Paulo ( SP) : Escola de Enfer m agem / USP; 1996.
11. Nat ional Pr essur e Ulcer Adv isor y Panel. Pr essur e ulcer p r e v a l e n ce , co st a n d r i sk a sse ssm e n t : co n se n su s dev elopm ent confer ence st at em ent . Decubit us 1989; 2( 2) : 2 4 - 8 .
1 2 . Na t i o n a l Pr e ssu r e Ul ce r Ad v i so r y Pa n e l . St a g e I assessm ent in darkly pigm ent ed skin [ on line] [ cit ed 2000 Nov 19] . Available from : ht t p: / / www.nuap.org/ / posit n4.ht m 13. Fr ant z RA, Gar dner S. Elder ly sk in car e: pr inciples of chronic wound care. J Geront ol Nurs 1994 Sept em ber; 20( 9) : 3 5 - 4 4 .
14. Lavery LA, Arm st rong DG, Harkless LB. Classificat ion of diabet ic foot wounds. Ost om y Wound Manage 1997 March; 43( 2) : 44- 8, 50, 52- 3.
15. van Rij swij k L. I ssues in chronic wound care: where do we g o f r om h er e? Ost om y Wou n d Man ag e 1 9 9 6 Nov em b er -Decem ber ; 4 2 ( 1 0 A Su ppl) : 7 0 S- 7 2 S.
16. Sussm an C, Bat es- Jensen B. Wound care: a collaborat ive p r a ct i ce m a n u a l f o r p h y si ca l t h e r a p i st s a n d n u r se s. Gait her sbur g: Aspen Publisher ; 1998.
1 7 . Me n e g h i n P, So a r e s L. Av a n ço s e m cu r a t i v o s. I n : Fernandes AT. I nfecção hospit alar e suas int erfaces na área da saúde. São Paulo ( SP) : At heneu; 2000. p. 998- 1007. 18. Bapt ist a CMC, Cast ilho V. Levant am ent o do cust o diret o do procedim ento com bota de unna em pacientes com úlcera v e n o sa . [ d i sse r t a çã o ] . Sã o Pa u l o ( SP) : Esco l a d e Enfer m agem / USP; 2 0 0 2 .
