3 7 2
Rev Lat ino- am Enfer m agem 2006 m aio- j unho; 14( 3) : 372- 7w w w . eer p. usp. br / r lae
PROFI LE OF PATI ENTS W I TH SPI NAL CORD I NJURI ES AND
OCCURRENCE OF PRESSURE ULCER AT A UNI VERSI TY HOSPI TAL
1Paula Cr ist ina Nogueir a2
Mar ia Helena Lar cher Calir i3 Van der lei José Haas4
Nogueir a PC, Calir i MHL, Haas VJ. Pr ofile of pat ient s w it h spinal cor d inj ur ies and occur r ence of pr essur e ulcer
at a univ er sit y hospit al. Rev Lat ino- am Enfer m agem 2006 m aio- j unho; 14( 3) : 372- 7.
Pat ient s w it h t r aum at ic spinal cor d inj ur y ( TSCI ) hav e an incr eased r isk of dev eloping pr essur e ulcer s ( PU) . I t is a r et r ospect iv e st udy done by r ev iew of r ecor ds in or der t o ident ify t he char act er ist ics of pat ient s w ho w er e assist ed at a t er t iar y hospit al as w ell as t he occur r ence of PU. Most pat ient s w er e m ale, w hit e and 36,2% bet w een 21 and 30 year s. The m ost com m on causes of TSCI w er e w ound by fir e w eapons follow ed by v ehicle cr ash/ ov er t ur n. Ther e w as a pr edom inance of inj ur y at t he t or acic lev el follow ed by cer v ical. The PU occur r ed in 2 0 pacient es ( 4 2 , 5 % ) . The m ost fr equent r egions of occur r ence w er e t he sacr al and heels. Only 25% of t he r ecor ds had PU’s dim ensions char t ed, 80% st at ed t he aspect , and 52.1% did not st at e t he st age. Ther e is a need for bet t er docum ent at ion of PU so t hat int er v ent ions used for t r eat m ent can be ev aluat ed.
DESCRI PTORS: spinal cor d inj ur ies; decubit us ulcer ; nur sing car e; nur sing
PERFI L DE PACI ENTES CON LESI ÓN TRAUMÁTI CA DE MÉDULA ESPI ÑAL Y
OCURRENCI A DE ÚLCERAS POR DECÚBI TO EN UN HOSPI TAL UNI VERSI TARI O
Pacient es con lesión t r aum át ica de m édula espinal ( LTME) t ienen r iesgo elevado de desar r ollar úlcer as de pr esión ( UP) . Est e est udio r et r ospect ivo ident ificó a t r avés de la r evisión de las hist or ias clínicas en hospit al
n iv el I I I , car áct er íst icas de pacien t es at en didos y la ocu r r en cia de UP. La m ay or ía f u e de sex o m ascu lin o, blanca y el 36,2% ent r e 21 a 30 años de edad. La causa m ás fr ecuent e de LTME fue her ida por ar m a de fuego, seguida de choque/ volcadur a de aut o. Hubo pr edom inio de lesión a nivel t or áxico, seguido del cer vical. Las UP apar ecier on en 20 pacient es ( 42,5% ) . Las r egiones de m ay or fr ecuencia fuer on la sacr a y los calcaneos. Solo el 25% de las hist or ias t enía r egist r o sobr e la dim esión de la UP, el 80% descr ibió el aspect o y el 52,1% no r eg ist r ó el est ad io. Se ob ser v a la n ecesid ad d e u n m ej or r eg ist r o d e las UP p ar a q u e las in t er v en cion es ut ilizadas en el t r at am ient o puedan ser ev aluadas.
DESCRI PTORES: t r aum at ism os de la m édula espinal; úlcer a por decúbit o; at ención de enfer m er ía; enfer m er ía
PERFI L DE PACI EN TES COM LESÃO TRAUMÁTI CA DA MEDULA ESPI N HAL
E OCORRÊNCI A DE ÚLCERA DE PRESSÃO EM UM HOSPI TAL UNI VERSI TÁRI O
Pacient es com lesão t r aum át ica da m edula espinhal ( LTME) t êm r isco elevado par a desenvolver úlcer a de pr essão ( UP) . O est u do é r et r ospect iv o e, pela r ev isão dos r egist r os n os pr on t u ár ios iden t if icar am - se as car act er íst icas dos pacien t es at en didos em h ospit al t er ciár io e das UP. A m aior ia dos su j eit os er a do sex o m asculino, br anco e 36, 2% ent r e 21 e 30 anos de idade. A causa m ais fr eqüent e da LTME foi fer im ent o por ar m a d e f og o seg u id a p or colisão/ cap ot am en t o d e v eícu lo. Hou v e p r ed om ín io d a lesão em n ív el t or ácico seguido pelo cer v ical. A UP ocor r eu em 20 pacient es ( 42, 5% ) . Os locais de m aior fr eqüência for am a r egião
sacr al e calcân eos. Apen as 2 5 % dos pr on t u ár ios t in h am o r egist r o da dim en são da UP, 8 0 % apr esen t av a o r egist r o do aspect o e em 52,1% não havia o r egist r o do est ágio. Obser va- se a necessidade de m elhor r egist r o das UP par a que as int er v enções ut ilizadas par a t r at am ent o possam ser av aliadas.
DESCRI TORES: t r aum at ism os da m edula espinhal; úlcer a de decúbit o; cuidados de enfer m agem ; enfer m agem
1
St udy ext r act ed fr om a Mast er ’s Thesis, par t ially funded by Capes and Fapesp; 2 M.Sc. in Nur sing, RN, Univer sit y of São Paulo at Ribeir ão Pr et o Medical School Hospit al das Clínicas; 3 RN, Associat e Pr ofessor, e- m ail: m hcalir i@eer p.usp.br ; 4 Junior Pr ofessor ( Pr odoc) , e- m ail: haas@eer p.usp.br. Univer sit y of São Paulo at Ribeir ão Pr et o College of Nur sing, WHO Collabor at ing Cent r e for Nur sing Resear ch Developm ent
D ispon ív e l e m lín gu a por t u gu e sa n a SciELO Br a sil w w w .scie lo.br / r la e
I NTRODUCTI ON
P
at ien t s w it h t r au m at ic sp in al cor d in j u r y ( TSCI ) suffer a spinal cor d t r aum a due t o hyper flect ionor hyper ext ension of t he head and neck, com pr ession
or r ot at ion of t h e v er t ebr al body, or by pen et rat in g
inj uries, w hich cause a t ot al or part ial rupt ure of spinal
t r a n sm i ssi o n , l e a d i n g t o a ch a n g e i n t h e n o r m a l
funct ioning of t he spine( 1).
The spinal cor d is par t of t he Cent r al Ner vous
Sy st em , cont ained in t he v er t ebr al colum n, and any
d am ag e cau sed b y a p h y sical ag en t ( in j u r y b y f ir e
w e a p o n ) o r v i o l e n t s h o c k ( f a l l s o r a u t o m o b i l e
accident s) can cause a per m anent loss of sensit iv it y
and/ or m ot r icit y, leading t o quadr iplegia or paraplegia.
Qu adr iplegia r esu lt s f r om a ch an ge in t h e f u n ct ion s
o f t h e u p p er l i m b s, t r u n k , l o w er l i m b s an d p el v i c
or g an s. Par ap leg ia r ef er s t o t h e loss of t h e m ot or
and/ or sensit iv e funct ion in t he t hor acic, lum bar and
sacr al segm ent s. The anat om ic locat ion of t he inj ur y
is dir ect ly r elat ed t o t he t r aum a m echanism , and t he
l e v e l o f n e u r o l o g i c a l d a m a g e i s b a s e d o n t h e
assessm ent of sensit iv it y and m ot or funct ion( 2).
TSCI m or e f r equ en t ly af f ect s y ou n g adu lt s.
Most in j u r ies occu r in m en , in t h e secon d or t h ir d
decade of life( 3).
Due t o decr eased m obilit y and sensit ivit y, all
pat ien t s w it h TSCI pr esen t h igh r isk s of dev elopin g
pr essur e ulcer s ( PU)( 4).
Pr essur e ulcer can be defined as “ a localized
ar ea of t issu e n ecr osis t h at t en ds t o dev elop w h en
soft t issue is com pr essed bet w een a bone pr om inence
and a har d sur face for a pr olonged per iod of t im e”( 5).
I t is st aged fr om I t o I V, accor din g t o t h e dept h of
o b s e r v e d t i s s u e d a m a g e . I n s t a g e I , PU i s
char act er ized by a nonblanchable er y t hem a of int act
sk in. I n indiv iduals w it h dar k er sk in, discolor at ion of
t he sk in, w ar m t h, edem a and har dness m ay also be
in d icat or s. St ag e I I is m ar k ed b y p ar t ial- t h ick n ess
sk in loss, in v olv in g t h e ep id er m is, d er m is or b ot h .
The inj ur y is super ficial and clinically pr esent s as an
a b r a s i o n , b l i s t e r o r s h a l l o w c r a t e r. S t a g e I I I i s
ch ar act er ized by t ot al- t h ick n ess sk in loss, in v olv in g
d am ag e t o or n ecr osis of su b cu t an eou s t issu e t h at
m ay ex t en d d ow n t o, b u t n ot t h r ou g h , u n d er ly in g
fascia. The pressure ulcer clinically appears as a deep
crat er. I n st age I V, t he PU is m ar ked by full- t hickness
sk in loss w it h ex t ensiv e dest r uct ion, t issue necr osis,
or dam age t o m uscle, bone or suppor t ing st r uct ur es,
for ex am ple: t endons or j oint capsules( 5).
Depending on t he dept h of t issue inj ur y, PU
c a n l e a d t o s e r i o u s c o m p l i c a t i o n s , s u c h a s
ost eom y elit is, sep t icem ia an d ev en d eat h . Besid es
financial losses t o pat ient s and relat ives, t he problem
also cau ses psy ch ological disor der s an d im pedes or
com plicat es t he pat ient ’s part icipat ion in rehabilit at ion
p r og r am s( 6 ).
For bot h in div idu als an d car egiv er s, PU can
result in lost w ork or school t im e, im paired com m unit y
r eint egr at ion, r educed qualit y of life and loss of
self-est eem( 4 ).
Tr a d i t i o n a l l y, t h e n u r si n g t e a m h a s b e e n
responsible for m aint aining skin and underlying t issue
in t egr it y t o pr ev en t PU, alt h ou gh ot h er h ealt h t eam
p r o f e s s i o n a l s n e e d t o b e i n v o l v e d d u e t o t h e
m ult icausal nat ure of t he problem . I n t he int ernat ional
cont ext , t he pr esence of PU has been pr esent ed as a
healt h ser v ice qualit y indicat or( 7).
M o s t PU c a n b e p r e v e n t e d b y a d o p t i n g
ad eq u at e p at ien t car e m easu r es an d b y ed u cat ion
f o r p r o f e ssi o n a l s, p a t i e n t s a n d f a m i l y m e m b e r s;
h o w ev er, i n st i t u t i o n s a l so n eed t o b e i n v o l v ed t o
pr ov ide t he necessar y condit ions for car e deliv er y( 8).
I n t er n at ion al lit er at u r e h igh ligh t s t h at , u n t il
t he st ar t of Wor ld War I I , societ y adopt ed a pessim ist
at t it ude t ow ar ds pat ient s w it h TSCI . The pr esence of
PU w as con sid er ed as a f at alit y an d an u n solv ab le
pr oblem , t hat is, “ w hich should not be t r eat ed”( 9). Lat er,
m e d i c a l , s c i e n t i f i c a n d t e c h n o l o g i c a l a d v a n c e s
pr ovided t he necessar y condit ions t o change t his dar k
p er sp ect i v e a n d , t o d ay, w e k n o w t h a t PU ca n b e
avoided and successfully t r eat ed, alt hough individuals
w it h spinal cord inj uries w ill alw ays face high risks of
dev eloping t hese ulcer s( 4 ).
I n Br azil, a r et r ospect iv e st u dy( 1 0 ) iden t ified
t hat , in a gr oup of 54 TSCI pat ient s hospit alized in a
f o u r - y ea r p er i o d , 3 4 ( 6 2 . 9 % ) p r esen t ed PU u p o n
adm ission or during t heir st ay in hospit al. This research
did not find an associat ion bet w een t he level of TSCI
and presence of inj uries, alt hough hospit alizat ion w as
longer for pat ient s w it h PU in com parison w it h persons
w it hout ulcer ( p= 0. 000) . Anot her st udy at t he sam e
t eaching hospit al( 8), inv olv ing nur sing t eam m em ber s
w h o a t t e n d e d p a t i e n t s w i t h TSCI , i d e n t i f i e d t h a t
pr ofessionals at t r ibut ed t he pr esence of PU t o pat ient
-relat ed fact ors, t o t he care process and t he inst it ut ional
st r u ct u r e, in d icat in g t h e m u lt icau sal n at u r e of t h is
p r o b l em .
A s PU c o n t i n u e s b e i n g o n e o f t h e m a i n
s e c o n d a r y c o m p l i c a t i o n s o f TS CI , w e a i m e d t o
3 7 4
Rev Lat ino- am Enfer m agem 2006 m aio- j unho; 14( 3) : 372- 7w w w . eer p. usp. br / r lae Pr ofile of pat ient s w it h spinal...
Nogueir a PC, Calir i MHL, Haas VJ.
t e a ch i n g h o sp i t a l , a s w e l l a s t h e o ccu r r e n ce a n d
ch ar act er ist ics of t h e PU r egist er ed in t h e pat ien t s’
ch ar t s.
METHODS
We c a r r i e d o u t a r e t r o s p e c t i v e a n d
quant it at ive st udy at t he Ribeirão Pret o Medical School
H o s p i t a l d a s Cl ín i c a s . D a t a w e r e c o l l e c t e d b y
review ing t he chart s of adult pat ient s hospit alized w it h
TSCI , under t he r esponsibilit y of t he or t hopedics and
neur osur gical t eam s, fr om 2000 t o 2003.
Th e r esear ch pr oj ect w as su bm it t ed t o an d
ap p r ov ed b y t h e Reg u lat ion an d Et h ical St an d ar d s
Com m ission at t h e place of st u dy. Nex t , w e car r ied
out a survey at t he Medical Filing and St at ist ics Service
( SAME) t o ident ify t he char t s of pat ient s hospit alized
d u r i n g t h e a b o v e m e n t i o n e d p e r i o d , u s i n g
I n t er n at ion al Classif icat ion of Diseases ( I CD) . Th e
ch a r t s w e r e r e v i e w e d t o i d e n t i f y w h i ch su b j e ct s
at t ended t o t he r esear ch inclusion cr it er ia: diagnosis
of TSCI , age of 18 year s or older at t he t im e of t r aum a
a n d i n f o r m a t i o n r e c o r d s r e l a t e d t o t h e f i r s t
hospit alizat ion aft er t he t r aum a.
Dat a w er e collect ed in 2 0 0 4 , u sin g a f ou r
-p ar t in st r u m en t . Par t on e r ef er r ed t o d em og r a-p h ic
var iables: gender, civ il st at us, sk in color ( consider ing
w h it e an d n ot w h it e) an d age r an ge. Par t t w o w as
r elat ed t o dat a about t he TCSI , such as t he t y pe of
occu r r en ce t h at led t o t h e t r au m a an d in it ial car e
co n d i t i o n s. Pa r t t h r e e co n si d e r e d d a t a a b o u t t h e
neurological level of t he inj ury and condit ions for care
by t he m ult ipr ofessional t eam , and par t four included
i n f o r m a t i o n r e l a t e d t o t h e o ccu r r e n ce o f PU a n d
char act erist ics t hat should be r egist er ed on t he char t :
locat ion ( anat om ical region) , classificat ion and general
appear ance, such as dim ension, aspect of w ound bed
and m ar gins, odor( 4).
Af t er r ev iew in g each ch ar t , v ar iab les w er e
co d ed an d a d at ab ase w as el ab o r at ed . Dat a w er e
t r a n scr i b e d t o w o r k sh e e t s a n d t h e d a t a b a se w a s
v a l i d a t e d t h r o u g h d o u b l e t y p i n g i n i n d e p e n d e n t
w or k sheet s. The st at ist ical SPSS ( St at ist ical Pack age
for Social Science) w as used for dat a analy sis.
RESULTS AND DI SCUSSI ON
The sur v ey at t he SAME ident ified 47 char t s
of p at ien t s w h o at t en d ed t o t h e r esear ch cr it er ia.
These const it ut ed t he st udy populat ion.
Table 1 pr esent s t he r esult s of t he subj ect s’
dem ogr aph ic an d clin ical pr ofile.
Ta b l e 1 - D i s t r i b u t i o n o f s u b j e c t s w i t h TS CI
h osp it alized in a u n iv er sit y h osp it al in 2 0 0 0 - 2 0 0 3 ,
a cco r d i n g t o d e m o g r a p h i c a n d cl i n i ca l v a r i a b l e s.
Ribeir ão Pr et o, 2 0 0 4
s e l b a i r a
V n %
r e d n e G e l a
M 45 95.8
e l a m e
F 02 04.2
s u t a t S l i v i C e l g n i
S 20 42.6
r e n t r a p h t i w r o d e i r r a
M 27 57.4
r o l o c n i k S e t i h
W 32 68.1
e t i h w t o
N 15 31.9
e g n a r e g A 0 2
< 08 17.0
0 3 -1
2 17 36.2
0 4 -1
3 05 12.5
0 5 -1
4 07 14.9
0 6 -1
5 03 06.4
0 6
> 03 06.4
a m u a r T f o e s u a C n o p a e w e r i f y b d n u o
W 21 44.7
n r u t r e v o / h s a r c e l c i h e
V 11 23.4
ll a
F 08 17.0
r e v o n u
R 03 06.4
g n i v i
D 03 06.4
e l c y c r o t o
M 01 02.1
l e v e L y r u j n I l a c i g o l o r u e N l a c i v r e
C 19 40.4
c i c a r o h
T 21 44.7
r a b m u
L 07 14.9
On l y t w o su b j e ct s w e r e w o m e n . A l a r g e
m aj or it y of par t icipant s w er e young adult s, w it h 36.2%
bet w een 21 and 30 year s old. As t o skin color, 68.1%
w er e w hit e and, w hat civil st at us is concer ned, 57.4%
w er e m ar r ied or h ad a par t n er. Wit h r espect t o t h e
t ype of accident t hat caused t he t r aum a, 44.7% w er e
due t o w ounds by gun shot , follow ed by vehicle cr ash/
ov er t ur n ( 23. 4% ) . Ev en w hen w e classified t oget her
m ot or v ehicle- r elat ed accident s ( cr ash/ ov er t ur n; r un
over and m ot or cycle) , t he num ber of event s ( 31.9% )
w as st ill low er t h an t r au m as cau sed by gu n sh ot s .
I nj ur ies m ost fr equent ly affect ed t he t hor acic r egion
( 44. 7% ) , follow ed by t he cer v ical r egion ( 40. 4% ) .
Th e r esu lt s, t h at v ict im s of TSCI ar e m ost
fr equ en t ly y ou n g adu lt m en ar e con fir m ed by ot h er
aut hor s in Br azilian and int er nat ional lit er at ur e( 1- 3).
Rel at ed t o t h e h i g h er f r eq u en ci es o f TSCI
caused by gun shot , t his t endency is obser ved in Br azil
and ot her par t s of t he w or ld, as a r esult of incr eased
A st udy car r ied out at t he sam e inst it ut ion ( 10)
bet w een 1996 and 1999 found t hat , in a gr oup of 54
pat ient s w it h TSCI , m ost vict im s w er e under 38 ( 75% ) .
Th e in j u r y af f ect ed t h e t h or acic lev el in 4 6 . 3 % of
pat ient s and t he cer v ical r egion in 40. 7% . How ever,
in t er m s of t he t ype of accident t hat led t o TSCI , t he
m a i n ca u se o f t r a u m a w a s a u t o m o b i l e a cci d e n t s
( 48. 1% ) , follow ed by gun shot ( 25. 9% ) , as opposed
t o our r esult s.
Man y accid en t s t h at lead t o TSCI cou ld b y
a v o i d e d b y p r e v e n t i o n c a m p a i g n s , t o a l e r t t h e
p op u lat ion ab ou t in j u r y - cau sin g r isk b eh av ior, su ch
as diving in shallow w at er s and t he need t o evaluat e
dept h befor e div ing, for ex am ple( 11). I nj ur ies caused
b y f alls cou ld also b e r ed u ced if civ il con st r u ct ion
w or k er s adher ed t o r ecom m endat ions about t he use
of pr ot ect iv e m easu r es( 2 ).
Tables 2 and 3 pr esent r esult s about PU and
t h eir ch ar act er ist ics, as r eg ist er ed in t h e su b j ect s’
ch ar t s.
Table 2 - Num ber and anat om ic r egion of PU in adult
p at ien t s w it h t r au m at ic sp in al cor d in j u r y. Rib eir ão
Pr et o, 2004
s e l b a i r a V U P f o r e b m u
N n %
0 27 57.4
1 7 15.0
2 5 10.6
3 4 8.5
4 3 6.4
5 1 2.1
U P f o n o i g e r c i m o t a n A l a r c a
S 17 36.9 l
e e
H 8 17.4
l a e t u l
G 5 10.8
a i h c s
I 5 10.8
x y c c o
C 3 6.5
r e t n a h c o r
T 2 4.4
il o e ll a
M 2 4.4
s e v l a
C 2 4.4
e a l u p a c
S 2 4.4
I n t he gr oup of 47 subj ect s, 20 ( 42.5% ) had
PU, w it h an aver age of 2.3 PU per pat ient . One single
p at i en t h ad 0 5 PU i n d i f f er en t b o d y r eg i o n s. Tw o
( 4 . 3 % ) of t he r egist er ed PU w er e pr esent w hen t he
p a t i e n t w a s a d m i t t e d t o h o s p i t a l . I n t e r m s o f
anat om ical region, ulcers w ere found in differ ent body
r egions, but t he m ost affect ed sit es w er e t he sacr al
r egion ( 37% ) , follow ed by t he heels ( 17.4% ) . I n t hese
r egions, PU happen w hen pat ient s ar e k ept in pr one
or dor sal posit ion for a long per iod of t im e, w it h t he
b ed in a h or izon t al p osit ion , an d ar e ag g r av at ed if
t h e b ed h ead is r aised t o an an g le b ig g er t h an 3 0
degrees, like in Fow ler’s posit ion( 5). The pr oblem get s
w or se w h en r eg u lar h osp it al m at t r esses ar e u sed ,
w hich ar e har d and, due t o w ear and t ear, fr equent ly
p r e se n t a d e p r e ssi o n i n t h e sa cr a l r e g i o n ( w h i ch
r eceiv es t h e gr eat est body w eigh t in t h is posit ion ) ,
w hich causes a lar ger pr essur e incr ease on t hat sit e
– t he m ain et iological fact or for developing PU( 7). I t is
k n ow n t h at capillar y closin g pr essu r e is 3 2 m m / Hg
and t hat , w hen t he com pr ession degr ee ex ceeds t his
p r essu r e, cell hy p ox ia an d isch em ia occu r, cau sin g
t i s s u e d a m a g e a n d b r e a k i n g s k i n i n t e g r i t y, a s
ev idenced by t he PU( 7).
Thus, st aying in t he sam e posit ion for a long
t im e and on inadequat e m at t r esses, ar e fact or s leading
t o t he developm ent of PU( 5).
I n t he heel r egion, PU appear for t he sam e
r eason, but can be aggr avat ed if pat ient s w it h spinal
cor d inj ur y pr esent const ant foot fr ict ion as a r esult
o f m u scl e sp asm s( 4 ). Pr ev en t i o n m easu r es i n cl u d e
elevat ing t he feet by placing pillow s under t he pat ient s’
calv es, ch an g in g p osit ion f r eq u en t ly, p r ot ect in g t h e
sk i n w i t h t r a n sp a r e n t f i l m d r e ssi n g s, u si n g sk i n
hy dr at ing cr eam s and det ect ing ulcer s ear ly t hr ough
a d a i l y e x a m i n a t i o n o f t h e r e g i o n s ( 4 - 5 ). O t h e r
f r eq u en t ly ob ser v ed PU, lik e in t h e t r och an t er an d
m alleoli region, are due t o excessive pressure caused
by r em aining in t he lat er al posit ion for a long t im e.
As subcut aneous t issue is not t hick in t hese r egions
and t her e is no m uscle m ass, pr essur e ulcer s appear
fast er and r each t he deep layer s in few days( 4- 5). Early
det ect ion and t r eat m ent can av oid com plicat ions.
Table 3 - St ages of PU in adult pat ient s w it h t raum at ic
sp in al cor d in j u r y, accor d in g t o locat ion ( an at om ic
r egion) . Ribeir ão Pr et o, 2 0 0 4
s e g a t
S PU n o i t a c o
L I II III IV Norecord Total l
a r c a
S - 2 1 4 10 17 l
e e
H 2 2 1 - 3 8
l a e t u l
G 1 - - - 4 5
a i h c s
I - 2 - 2 1 5
x y c c o
C - 1 - - 2 3
r e t n a h c o r
T 1 - - - 1 2
il o e ll a
M - 1 - - 1 2
s e v l a
C - - 1 - 1 2
e a l u p a c
S 1 - - - 1 2
U P l a t o T 5 ) % 9 . 0 1 ( 8 ) % 4 . 7 1 ( 3 ) % 5 . 6 ( 6 ) % 0 . 3 1 ( 4 2 ) % 2 . 2 5 ( 6 4 ) % 0 0 1 (
I n 5 2 . 2 % of PU cases, t h e pat ien t s’ ch ar t s
d i d n o t c o n t a i n a n y d o c u m e n t a t i o n a b o u t t h e
3 7 6
w a s r e g i st e r e d , 0 3 ( 6 . 5 % ) w e r e i n st a g e I I I , 0 5
( 1 0 . 9 % ) in st age I an d 6 ( 1 3 . 0 % ) in st age I V. Th e
deepest PU ( st age I V) w er e iden t if ied in t h e sacr al
( 4) region and ischia. I n st age I I I , ulcer s w er e found
in t he sacral region, heels and calves. I n t he lat t er, in
v iew of t he docum ent at ion in t he pat ient ’s char t , t he
PU w as pr obably due t o t he use of a posit ioner for t he
low er lim bs, t o av oid t he dev elopm ent of a clubfoot .
This caused pr essur e in t he ar ea and cont r ibut ed t o
t he dev elopm ent of PU.
A st udy t hat analy zed dat a of TSCI pat ient s
at t en d ed in t h e Am er ican r eg ion al sy st em f ou n d a
su bst an t ial decr eased in t h e pr opor t ion of st age I I I
and I V pr essur e ulcer s dur ing t he annual ev aluat ion
a f t e r t h e i n j u r y. Th e a u t h o r s( 1 2 ) a r g u e t h a t t h i s
d e c r e a s e c a n b e a t t r i b u t e d t o d i f f e r e n t f a c t o r s ,
i n cl u d i n g b e t t e r k n o w l e d g e a b o u t ca u se s o f PU,
i m p r o v e d p a t i e n t ca r e a n d f o l l o w - u p , a s w e l l a s
incr eased opt ions of suppor t sur faces and pillow s for
pat ien t s.
I n t he pr eviously m ent ioned st udy( 10), carried
o u t a t t h e sa m e i n st i t u t i o n , 1 6 ( 3 6 . 4 % ) su b j ect s
pr esen t ed st age I I PU, 1 4 ( 3 1 . 8 % ) st age I I I an d 4
( 9.1% ) st age I V. I n our st udy, w e found an incr ease
in st age I V ulcers, alt hough no inferences can be m ade
about any changes, as bot h ar e r et r ospect ive st udies,
based on char t r ev iew .
A s t o i n f o r m a t i o n a b o u t t h e g e n e r a l
appear an ce of t h e PU, am on g t h e 2 0 su bj ect s w h o
pr esent ed t hese inj ur ies, docum ent at ion about aspect
w er e f o u n d i n 1 6 ch ar t s ( 8 0 % ) , w h i l e d at a ab o u t
dim ensions w er e found in only 05 ( 25% ) . This finding,
t h at is, t h at 7 5 % of p at ien t ch ar t s d o n ot con t ain
inform at ion about t he dim ensions of t he PU, indicat es
a lack of dat a r egist r at ion w it h a view t o an obj ect ive
assessm en t of car e r esu lt s, as t h e im pr ov em en t of
PU can be ev idenced by a r educt ion of it s ar ea and
c h a n g e o f a s p e c t , w i t h d e c r e a s e d e x u d a t e a n d
odor( 4, 13).
CONCLUSI ONS
This st udy allow ed us t o conclude t hat :
- Pa t i e n t s w e r e p r e d o m i n a n t l y m e n ( 9 5 . 8 % ) ,
co n si d e r e d y o u n g a d u l t s ( 2 1 – 3 0 y e a r s) , w h i t e
( 68.1% ) , m ar r ied or liv ing w it h a par t ner ( 57.4% ) .
- Th e m ain ex t er n al cau se of t r au m a w as accid en t
d u e t o W FW ( 4 4 . 7 % ) , f o l l o w e d b y a u t o m o b i l e
acciden t s: v eh icle cr ash / ov er t u r n ( 2 3 . 4 % ) .
- Most inj ur ies occur r ed in t he t hor acic r egion ( 44.7% ) ,
follow ed by t he cer v ical lev el ( 40. 4% ) .
- I n t he st udy populat ion of 47 pat ient s, 20 ( 42.5% )
pr esent ed r egist er s of PU, t ot aling 46 ulcer s, w it h an
av er age of 2. 3 ulcer s per pat ient .
- Ulcer s w er e dist r ibut ed acr oss differ ent body r egions,
b u t PU m ost f r eq u en t l y af f ect ed t h e sacr al r eg i on
( 36.9% ) , follow ed by t he heels ( 17.4% ) .
- I n 52.2% of ulcer s, pat ient s’ char t s did not r egist er
t h e c l a s s i f i c a t i o n s t a g e . Th i s i n f o r m a t i o n w a s
r egist er ed for 2 2 ulcer s, 3 ( 6 . 5 % ) of w hich w er e in
st age I I I , 5 ( 10.9% ) in st age I and 6 ( 13.0% ) in st age
I V. Th e deepest u lcer s ( st age I V) w er e iden t if ied in
t he sacr al r egion ( 4) and ischia. I n st age I I I , ulcer s
w er e found in t he sacr al r egion, heels and calv es.
- As t o in f or m at ion abou t t h e ch ar act er ist ics of t h e
PU, only 05 pat ient char t s ( 25% ) cont ained r egist er s
about ulcer dim ensions and 16 ( 80% ) about aspect .
Dat a found in t his st udy need t o be analyzed
b y h e a l t h p r o f e ssi o n a l s, w i t h a v i e w t o i m p r o v e
docu m en t at ion abou t PU locat ion an d descr ipt ion of
dim ensions and char act er ist ics, and also w it h a v iew
t o using guidelines recom m endat ions for t he select ion
o f ad eq u at e i n t er v en t i o n s, w h i ch i n cl u d e p r essu r e
r elief in t he ulcer sit e and t ype of t opical t r eat m ent .
I ncom plet e or er r oneous r egist er s in pat ient
c h a r t s , c a u s e d b y “ b a d l y w r i t t e n , c o n f u s i n g ,
incom plet e or t echnically unsubst ant iat ed not es, can
easily ext r apolat e t o t he under st anding t hat t he sam e
lack of professionalism occurred in at t it udes or pat ient
care” ( 14).
Lit er at ur e highlight s t hat negligence in char t
r egist er s can r esult fr om t he am ount of t im e spent t o
m ak e descr ipt iv e not es on PU condit ions, as w ell as
f r om pr of ession als’ lack of k n ow ledge. How ev er, f or
legal an d et h ical r eason s, as w ell as f or m on it or in g
t r eat m en t an d assessin g it s ef f icacy, docu m en t at ion
is essent ial ( 15).
Educat ional pr ogr am s ar e needed, infor m ing
st u d en t s an d p r of ession als ab ou t h ow t h ey sh ou ld
m ak e not es on t he char act er ist ics of pr essur e ulcer s
an d on p r ev en t ion an d t r eat m en t in t er v en t ion s, as
w ell as about t he legal im plicat ions of chart regist ers.
REFERENCES
1 . Hickey JV. Ver t ebr al an d spin al cor d in j u r ies. I n : Hick ey JV. Th e Clin ical p r act ice of n eu r olog ical an d n eu r osu r g ical nur sing. 5n d ed. Tex as: Lippincot ; 2 0 0 3 . p. 4 0 7 - 5 0 .
2 . D e f i n o H LA . Tr a u m a r a q u i m e d u l a r. M e d i c i n a 1 9 9 9 ; 3 2 ( 4 ) : 3 8 8 - 4 0 0 .
3 . Far o ACM. Do diagn óst ico à con du t a de en f er m agem : a t raj et ór ia do cuidar na r eabilit ação do lesado m edular. [ t ese] . São Pau lo ( SP) : Escola de En fer m agem / USP; 1 9 9 5 .
Rev Lat ino- am Enfer m agem 2006 m aio- j unho; 14( 3) : 372- 7 w w w . eer p. usp. br / r lae Pr ofile of pat ient s w it h spinal...
4. Par aly zed Vet er ans of Am er ica. Pr essur e ulcer pr ev ent ion and t r eat m ent follow ing spinal cor d inj ur y : a clinical pr act ice gu idelin e f or h ealt h - car e pr of ession als. USA: PVA; 2 0 0 0 . 5 . B e r g s t r o m N , A l l m a n RM, A l v a r e z OM, Ca r l s o n CE, Eag leset ein W, Fr an t z RA, et al. Pr essu r e u lcer in ad u lt s: Pr edict ion and Pr event ion. Rockville ( MD) : US Depar t m ent of Healt h an d Hu m an Ser v ices, Pu b lic Healt h Ser v ice Ag en cy for Healt h Car e Policy an d Resear ch ; 1 9 9 2 .
6 . Fa r o ACM. Fa t o r e s d e r i sco p a r a ú l ce r a d e p r e ssã o : subsídios par a a pr evenção. Rev Esc Enfer m agem USP 1999; 3 3 ( 3 ) : 2 7 9 - 8 3 .
7 . Mak lebust J, Sieggr een M. Pr essur e ulcer : Guidelines for p r ev en t ion an d Man ag em en t . 3n d ed . Pen n sy lv an ia: Sp r in g Ho u se; 2 0 0 1 .
8 . Nogu eir a PC, Calir i MHL, San t os CB. Fat or es de r isco e m e d i d a s p r e v e n t i v a s p a r a ú l ce r a d e p r e ssã o n o l e sa d o m edular. Ex per iência da equipe de enfer m agem do HCFMRP-USP. Med i ci n a 2 0 0 2 ; 3 5 ( 1 ) : 1 4 - 2 3 .
9 . Gu t t m a n n L. S p i n a l Co r d I n j u r i e s : Co m p r e h e n s i v e m anagem ent and r esear ch. Ox for d: Black w ell; 1 9 7 3 . 1 0 . Car cinoni M, Calir i MHL, Nascim ent o MS. Ocor r ência de ú lcer a d e p r essão em in d iv íd u os com lesão t r au m át ica d a m edu la espin h al. Rev Min En fer m agem 2 0 0 5 ; 9 ( 1 ) : 2 9 - 3 4 . 1 1 . Si l v a CLC, D e f i n o H LA. Es t u d o e p i d e m i o l ó g i c o d a s fr at ur as da coluna cer vical por m er gulho na cidade de Ribeir ão Pr et o. Med icin a 2 0 0 2 ; 3 5 : 4 1 - 7 .
1 2 . McKi n l ey WO, Jack so n AB, Car d en as D D, D ev i v o MJ. Long t er m m edical com plicat ions aft er t r aum at ic spinal cor d in j u r y : a r eg ion al m od el sy st em s an aly sis. Ar ch Ph y s Med Reh a b i l 1 9 9 9 ; 8 0 ( 1 1 ) : 1 4 0 2 - 1 0 .
1 3 . Be r g st r o m N, Al l m a n RM, Al v a r e z OM, Ca r l so n CE, Eag leset ein W, Fr an t z RA, et al. Pr essu r e u lcer t r eat m en t : Pr edict ion and Pr event ion. Rockville ( MD) : US Depar t m ent of Healt h an d Hu m an Ser v ices, Pu b lic Healt h Ser v ice Ag en cy for Healt h Car e Policy an d Resear ch ; 1 9 9 4 .
1 4 . Og u i sso T. D i m en sõ es ét i co - l eg a i s d a s a n o t a çõ es d e enfer m agem no pr ont uár io do pacient e. Rev Paul Enfer m agem 2 0 0 3 ; 2 2 ( 3 ) : 2 4 5 - 5 4 .
1 5 . Pi e p e r B , M i k o l s C, M a n c e B , A d a m s W. N u r s e s ’ d o cu m e n t a t i o n a b o u t p r e ssu r e u l ce r s. D e cu b i t u s 1 9 9 0 ; 3 ( 1 ) : 3 2 - 4 .
