A patient was admitted to the ICU of a North-Northeast referral hospital for cancer treatment, located in Teresina-PI.
The patient is GBR, 94 years old, female, admitted for acute respiratory failure resulting from bronchoaspiration, with a history of pneumonia and diabetes mellitus associated with chronic bronchitis.
During admission there was considerable deterioration, with a perception of inability to keep the airways preserved, in addition to the use of accessory muscles, and therefore, orotracheal intubation was performed for comfort and vasoactive deterioration in the pattern of respiration, maintaining hemodynamic drugs.
During the physical examination, the patient was sedated with RASS-5, according to the Agi-Sedation-Sedation Scale totally sedated, under controlled assisted mechanical diarrhea, passive voiding, urinary incontinence
This evidences a significant increase in risk factors for the development of the lesion.
1.
Establishment plan
When related to the stress factors present, in this case, the presence of intrinsic factors such as age, mobility problems due to orotracheal intubation and urinary incontinence was evidenced, which was treated to solve with hydric catheterization, reducing the acid skin contact.
In addition, fecal incontinence protected by persistent diarrhea complications was resolved with effective diaper changes in standard hours intercalated with times of occurrence of the event, added to the use of creams.
We observed the presence of a damaged neurological level due to continuous sedation, along with inadequate nutrition and lying down.
All of these stress factors mentioned by Neuman in his theory potentiate the appearance of PU, having an interrelationship between theory and clinical practice in the search for the best clinical evidence of care in the prevention of PU.14
The main concern of nursing, as well as other health professionals, is to help the client to achieve, maintain or preserve the existing stability, can be obtained through rigorous research of the patient, even emphasizing the need for universally available abstract situations.
Considering that one of the indicators of quality of life for patients admitted to the ICU is the health of patients, which leads to their well-being in the mental, physical and spiritual dimensions, which leads us to believe that the institutionalization of patients is a risk.
In this context, the risk scale manages to provide users with clinical evidence to support nursing actions, as a theoretical framework, which justifies the selection of the incidence of ulcers, the appearance of the PU factors, or the increase of these professionals' activities.
These stress factors, for Neuman, are considered a set of forces that can present as intrapersonal factors, interpersonal factors and extrapersonal factors, these forces can be grouped into biological, psychological, sociocultural and spiritual.
In this way, these combined forces can be related by increasing their actions, so in relation to the prevention of PUs using the quantitative Risk Score, the much that these factors can reinforce their actions when they are associated is observed.
Level of patient mobility and activity change in six subscales divided into sensory perception (test the ability to react significantly to discomfort-related pressure), moisture (refers to the level at which the skin is exposed to moisture),
All these subscales are scored from the least favorable (1) to the most favorable (4), with the exception of the last subscale Risk friction and shearing, scored from 1 to 3 with the sum of all of them being between 23-1411.
The following results were added to the scale established during the admission of the patient: sensory perception was very limited (2); humidity refers occasionally to wet mobility (3); activity due to inadequate bed (1) was evidenced by the following clinical signs:
Then, we proposed to analyze the stress factors that increase this occurrence, strengthened by Neuman as signs that can be identified by both his prevention and the nursing interventions strengthened by the defense lines stress,
With this, the continuity of the effectiveness of the use of the Scale is observed only if associated with the Theory only, and theoretical knowledge about the Neuman model is observed, since maintaining a low risk for patients bedridden with many possible stressors.
At the ICU, each finding was kept confidential for the assessment of each patient during the visit of patients with the entire multidisciplinary group twice a day, with their items being judged by everyone and, at the end, the specific conduct is already taken.
Thus, in view of the numerous activities performed in the ICU and the need for daily control not only by the nurse, but the entire multi-professional group, a checklist was developed to ensure that important actions were not forgotten.
Using a mnemonic device that uses the phrase "suspected or well" (although there is a known adaptation to well being treated or referred to well being treated), the term was not used previously is non-accurate.
Thus, the original idea of prevention of pressure ulcers was maintained, with the evaluation of the patient twice a day through the scale and continuity of treatment if the ulcers were already present.18,19
The "I" refers to the catheter infection by assessing phlogistic signs in the insertion need to maintain it; "T" tells us to check if there is an "intermittent" level of ventilation or if there is a "patient" medication need to close" medication administration;
Maintaining the integrity of the patient's skin during several days of hospitalization was observed, creating procedures such as keeping the skin always clean, moisture free with the help of disposable diapers in addition to the use of the barrier 11.
In addition to minimizing friction and shearing strength, not only does the patient keep beds between units, but also facilitates transport for tests or changes in position.
In patients with nutritional problems, who had high output due to poor absorption of enteral diet, this was noted as one of the possible causes of stress.
With the analysis of the multiprofessional group, it was observed that offering a high absorption diet rich in protein and calories could minimize the incidence of PU, with all these interventions evaluated, monitored and documented in medical records.19
It was observed that the association of the end of the strengthening of techniques still reduces the possibility of stress Neuman's theory was important in maintaining the integrity of the patient's skin, because the nurse can identify that the individual faces stressors, clinical behavior
