National Patient Safety Goals , health and medicine homework help

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N U TR ITIO N Nutrition and pressure ulcers: putting evidence into practice Carolyn Taylor Nutritional intake can have an effect on many areas of a patient’s health, while malnutrition specifically has a recognised role in pressure ulcer development. In this article, the author looks at whether there is any high quality evidence to recommend specific nutritional measures when trying to prevent pressure ulcers, as well as looking at overall recommendations for malnourished patients. Nutritional screening remains essential to help identify those patients most at risk of malnutrition and allows community nurses to prepare nutritional care plans and begin to correct any nutritional deficiencies. The author recommends that community nurses perform nutritional screening at any patient contact, be that in hospital, nursing home or in the patient’s own home. Recording the outcome of screening at regular intervals also helps to identify trends in a patient’s nutritional state and means that any reduction will be picked up quickly. KEYWORDS: Nutrition ■ Wounds ■ Dietitian ■ Malnutrition ■ Screening ressure ulcer treatment — and crucially prevention — has become a key focus for improving the quality of health care. Most pressure ulcers are now considered avoidable and consequently prevention has been included in domain 5 of the NHS Outcome Framework (Department of Health [DH], 2014), which has a stated aim of: ‘Treating and caring for people in a safe environment and protecting them from avoidable harm.’ P There is also a financial burden to consider, with pressure ulcers costing the NHS £1.4-2.lbn per year (Bennett et al, 2004), with category four pressure ulcers costing approximately £14,108 per patient (Dealey et al, 2012). The cost to Carolyn Taylor, research coordinator for combined community and acute care group; specialist dietitian, Dietetic Department, Northern General Hospital, Sheffield Teaching Hospital NHS Foundation Trust 38 JCN 2016, Vol 30, No 4 patients in terms of quality of life is also significant, with pressure ulcers affecting people’s ability to work and maintain independence. Any treatment that reduces the costly, painful and debilitating effect of pressure ulcers must be considered and the National Institute for Health and Care Excellence (NICE, 2014) recently released updated guidance on the prevention and management of pressure ulcers; in conjunction with this guidance, the NICE Quality Standards for pressure ulcers also highlight where improvements in patient care can be made and in particular what factors will prevent the development of pressure ulcers (NICE, 2015). A good nutritional status and fluid intake have always been considered important to both the prevention and management of pressure ulcers (Posthauer et al, 2015), and reference is made to the importance of nutritional status and nutritional intake throughout the recent NICE (2014) guidance. National Patient Safety Goals , health and medicine homework help

This is also highlighted in the quality standards (NICE, 2015), which repeatedly mention malnutrition as one of the risk factors for pressure ulcer development. Further evidence for the role of nutrition is provided by a recently updated Cochrane review into the specific role of nutrition in the prevention and management of pressure ulcers (Langer and Fink, 2014). While the Cochrane review showed much of the evidence to be of poor quality, it did demonstrate that nutritional supplements could reduce the development of pressure ulcers, although not to a significant level. The evidence that nutritional supplements could contribute to the healing of pressure ulcers was also of poor quality and difficult to draw conclusions from, although Langer and Fink (2014) specifically mentioned that there was emerging evidence that supplementing diet with the amino acid arginine (thought to become essential following trauma) may improve healing rates, although further research is required. While the evidence was found to be generally poor, Langer and Fink (2014) stated that it is still important to correct any nutritional deficiencies. This article reviews the current guidance relating to nutrition and how it affects the development of pressure ulcers, before considering how community nurses can put the recommendations into practice. N U TR ITIO N A N D PRESSURE ULCER PREVENTION Both of the NICE documents mentioned above (NICE, 2014; 2015), highlighted that malnutrition is one of the risk factors for pressure ulcer development. NUTRITION However, identifying malnutrition is difficult (Posthauer et al, 2015). While body weight is a factor in pressure ulcers, assessment is not straightforward, as being both underweight and overweight are known to increase the risk of pressure ulcer development. A low body weight (body mass index [BMI] of less than 18 Kg/m2) is associated with reduction in subcutaneous fat deposits, particularly over the bony prominences. Underweight patients are also more likely to be eating insufficiently and not meeting the recommended daily amounts of macro and micronutrients, meaning that they may not be eating sufficient energy, protein, vitamins and minerals. Conversely, being overweight (BMI over 25 Kg/m2) can also increase the risk of pressure ulcers due to higher body weight and poor mobility. There is also no guarantee that an overweight person’s dietary intake is balanced — just because they are eating does not mean they are taking in the required micronutrients. Loss of body weight, irrespective of the person’s initial weight, and especially if it is sudden and unplanned, is also a contributing risk factor for pressure ulcer development. This weight loss could be associated with illness or changes in social situation such as recent bereavement. As well as causing a loss of appetite, illness can also result in increased levels of inflammatory markers, such as C-reactive protein, which is also a known risk factor for pressure ulcers (Posthauer et al, 2015); the associated production of cytokines also results in a rising demand for energy and protein. National Patient Safety Goals , health and medicine homework help

At a time when illness may cause patients to lose their appetite, this increased metabolic load increases the risk of skin breakdown or reduced healing as energy and protein reserves are targeted for use elsewhere. The loss of muscle mass associated with age (sarcopenia) can also be a risk factor for pressure ulcers, however, while sarcopenia may not be avoidable, illness, lack of 40 JCN 2016, Vol 30, No 4 appetite, and the malabsorption of nutrients from the gastrointestinal tract can exacerbate it. IDENTIFYING THOSE AT RISK OF MALNUTRITION Identifying a patient’s risk of malnutrition is vital and was supported by the NICE guidelines and quality standard (NICE, 2014; 2015).There is additional NICE guidance that recommends the use of validated screening tools for identifying risk of malnutrition (NICE, 2012), which is also recommended by the National Pressure Ulcer Advisory Panel (NPUAP, 2014). The tool most frequently used is the Malnutrition Universal Screening Tool (MUST) (Todorvic et al, 2003), where patients are’scored’based on BMI, unintentional weight loss and any acute illness. MUST, therefore, relies on measuring the amount of weight the patient has lost, but this may be more difficult in those with limited mobility. In nursing and residential care, monitoring the weight of those patients with mobility issues can be made easier by creative use of equipment: ► Asking the patient to sit on scales ► Attaching scales to hoists when moving patients ► Using medical beds that incorporate a facility for weighing the patient. For patients at home, options for assessing weight change and risk of malnutrition include the following (Taylor, 2014): ► Measuring waist circumference, although this may be more difficult if a patient is unable to stand ► Measuring the patient’s arm circumference, although correlation may be affected by any pre-existing physical issues such as arm paralysis ► Hand-grip measurements can also be used as there is some correlation between declining strength and nutritional state (Flood et al, 2014) ► The physical Took’of the patient ► The fit of the patient’s clothes, i.e. are they loose? ► Fit of dentures —■the gum line will recede with weight loss ► Patient-reported lethargy ► Deteriorating skin condition or a non-healing pressure ulcer. The NICE (2015) quality standards recommended identifying pressure ulcer risk factors for all patients referred to community services and on admission to any healthcare setting. The guidelines also highlight that, along with assessing all risk factors, nutritional screening using a validated screening tool should be included and become part of routine care. National Patient Safety Goals , health and medicine homework help

As Posthauer et al (2015) suggested, early identification of malnutrition or risk of malnutrition can ensure that treatment begins quickly and will help prevent pressure ulcers developing as well as contributing to healing. For those patients not identified as being at risk of malnutrition, both a Cochrane review (Langer and Fink, 2014) and the NICE (2014) guidance highlighted that there was no specific evidence to recommend additional nutritional treatment to prevent pressure ulcers. In other words, if people are well nourished then increasing their nutritional intake to prevent pressure ulcers occurring is not recommended — only if they are malnourished can nutritional measures reduce the risk. HYDRATION There is limited evidence on how hydration affects pressure ulcer development and the recommendation is to ensure that the patient’s hydration status is adequate (NICE, 2014). Despite the lack of evidence in this area, dehydration is commonly accepted to affect skin turgor (the degree of elasticity of skin); in the author’s opinion it follows that this would increase the risk of pressure ulcers. All fluid losses, including urine, diarrhoea, excessive sweating, losses from pressure ulcers or other wounds, and stoma or fistula outputs, need to be accounted for. Fluid requirements will increase in certain circumstances such as fever and increased respiratory effort, while there will be excessive losses with NUTRITION S u d d e n loss o f b o d y w e ig h t Community nurses should be aware that loss of body weight, irrespective of the person’s initial weight, and especially if it is sudden and unplanned, is a contributing risk factor for pressure ulcer development. diarrhoea, vomiting and in people with wounds who will lose fluid through exudate leakage. While fluid requirements may reduce in the older population, their reduced thirst and anxiety about maintaining continence may reduce their desire to drink, thus making dehydration a risk in this population; similarly, the use of diuretics for the management of other long-term conditions such as heart failure and high blood pressure may increase fluid loss. NUTRITION AND PRESSURE ULCER MANAGEMENT There have been some studies into the effect of nutritional supplements on the treatment of pressure ulcers, however, these were generally of low quality, making specific recommendations difficult (NICE, 2014). The majority of research was associated with the use of oral nutritional supplements; either generic oral nutritional supplements, which contain a mixture of macro and micronutrients, or those containing specific amino acids or vitamins. In the NICE (2014) guidance, consideration was given to the costbenefit of nutritional supplements. In view of the inconclusive evidence around their use, and the cost of many of the generic oral nutritional supplements when used in the community (as opposed to in hospital where they are often negotiated at a contract price), the recommendation was that they should not be routinely used in the treatment of pressure ulcers when the patient’s nutritional intake is otherwise adequate. 42 JCN 2016, Voi 30, No 4 However, the guidance also stated that nurses should seek to correct any nutritional deficiency a patient may have, which may involve using nutritional supplements. National Patient Safety Goals , health and medicine homework help

For those with inadequate nutritional intake or poor nutritional status, a’food-first’ approach should be used to increase intake (the use of high energy and high protein foods often considered the more palatable and cost-effective way of meeting requirements), however, if this is tried and the patient’s intake remains insufficient, nutritional supplements may be the next line of treatment. This means that, rather than routinely providing nutritional supplements to patients who have a pressure ulcer, nurses need to undertake a nutritional assessment to identify those at risk of malnutrition so that they can be given the specific advice required to improve their nutritional intake. If patients are considered to be at risk of malnutrition following an assessment, then nutritional action plans need to be implemented. A review of their dietary intake would help to begin a conversation about the types and variety of foods they are eating. Typical dietary aspects that would raise concern include: ► Meals being missed ► Repetitive meal choices with limited variation in ingredients ► Inability to recall a variety of different meals recently eaten ► Indications that patient may be using smaller plates. Specific nutrition a l e le m en ts Specific nutritional elements are considered to promote pressure ulcer repair, including protein (both whole proteins and specific amino acids), iron, zinc and vitamin C. As mentioned above, the Cochrane review (Langer and Fink, 2014) stated that good quality evidence for the routine supplementary use of these elements is lacking, although the authors did suggest that more recent research into the use of arginine in the treatment of pressure ulcers is worth further investigation, as indications are that it may be beneficial in improving healing rates (Desneves et al, 2005; Cereda et al, 2009; Van Anholt et al, 2010). THE SCIENCE — MALNUTRITION Malnutrition can be defined as a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects both on tissue/ body form, body function, and clinical outcome (Elia, 2000). Malnutrition is a reversible risk factor for pressure ulcers in adults (NICE, 2014), therefore it is essential that all healthcare professionals are able to correctly identify those at risk early on and provide appropriate management. Nutritional screening should be implemented in all healthcare settings, particularly in the community where undernourished patients are harder to spot. Studies have shown that up to 93% of malnourished people are living in the community and this continues to be a major clinical and public health problem in the UK (Elia, 2000; Elia and Russell, 2009). Source: Rabess C (2015) Understanding the link between wound care and nutrition. J Comm Nurs 29(4): 60-5 Practical m easures Despite the lack of evidence for the positive effect of specific nutritional elements on healing pressure ulcers, there are some practical suggestions that can help community nurses improve patient’s overall nutritional intake: ► For those with a small appetite, eating little and often is frequently recommended. National Patient Safety Goals , health and medicine homework help

By eating small amounts frequently it is possible to improve nutritional intake. It is important that high calorie snacks (chocolates, sweets and crisps, etc) do not replace more nutritious meals or highly Credit: epsosLX&flickr. com Red Flag NUTRITION ► ► ► ► nutritious snacks such as cheese and biscuits, full-fat yoghurts, fruitcake, teacakes, scones, crumpets, nuts and cereal bars So-called ‘milky’ drinks can help to improve protein intake. Cheese and cream can also be added to meals, for example cheese can be grated over mashed potatoes. This will not increase the volume of food eaten, but will make every mouthful more nourishing In patients who may struggle to prepare full meals,’ready meals’ can provide a nourishing alternative and can be easier for patients to access, especially if they are being advised to rest. There are also companies that will deliver meals to the patient’s home Frozen vegetables can help to add variety to meals — handfuls of different vegetables can be cooked in one meal Sandwiches, toast and jacket potatoes can all be nourishing when prepared with a variety of fillings or toppings. Local community and hospital dietetic departments will usually have patient literature available that covers these strategies. CONCLUSION While there is a lack of high quality evidence to recommend specific nutritional measures when trying to prevent pressure ulcers or promote ulcer healing in well-nourished patients, there are some consistent overall recommendations for malnourished patients. Nutritional screening remains essential to help identify those patients most at risk of malnutrition, which will allow community nurses to prepare appropriate nutritional care plans and begin to correct any nutritional deficiencies. It is recommended that community nurses should perform nutritional screening at any patient contact, be that in hospital, nursing home or in the patient’s own home. The NICE guidelines for nutritional support in adults recommend the use of a validated 44 JCN 2016, Vol 30, No 4 screening tool such as MUST (NICE, 2012), and this is now widely used as a simple measure for identifying patients at nutritional risk. Recording the outcome of these screening tools at regular intervals can help to identify trends in a patient’s nutritional state and mean that any reduction will be picked up quickly. Available online: www.nice.org.uk/ guidance/qs24/chapter/quality-statement1-screening-for-the-risk-of-malnutrition (accessed 23, March, 2016) NICE (2014) Pressure ulcers: prevention and management. Available online: www.nice. org.uk/guidance/cgl79 (accessed 24 June, 2016) NICE (2015) Pressure ulcers: NICE Quality Further research into the role of nutrition in promoting pressure ulcer healing is required. This is echoed by the James Lind Pressure Ulcer Partnership (www.jla.nihr.ac.uk), which has highlighted diet and pressure ulcer research as one of its key areas for further investigation. National Patient Safety Goals , health and medicine homework help

JCN REFERENCES Bennett G, Dealey C, Posnett J (2004) The cost of pressure ulcers in the UK. Age Ageing 33(3): 230-235 Cereda E, Gini A, Pedroli C,Vanotti A (2009) Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomised controlled trial. Geriatrics Society 57(8): 1395-1402 Dealey C, Posnett J, Walker A (2012) The cost of pressure ulcers in the United K ingdom./ Wound Care 21(6): 261-6 Desneves KJ,Todorovic BE, Cassar A, Crowe TC (2005) Treatment with supplementary Standards. Available online: www.nice.org. uk/guidance/qs89 (accessed 24 June, 2016) NPUAP (2014) Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Available online: http://www.npuap.org (accessed 24 June, 2016) Posthauer ME, Banks M, Dom er B & Schols, J (2015) The Role of Nutrition for Pressure Ulcer Management: NPUAP EPUAP, and Fhn Fhcific Pressure Injury Alliance White Paper. Adv Skin Wound Care 28(4): 175-88 Taylor C (2014) Looking at malnutrition from the patient’s perceptive. / Comm Nurs 28(2): 38-44 TodorvicV, Russell C, Elia M (2003) The M U S T ‘ Explanatory Booklet. A guide to the Malnutrition Universal Screening Tool’for Adults. Available online: www.bapen.org. uk (accessed 24 June, 2016) Van Anholt RD, Sobotka L, Meijer ER et al (2010) Specific nutritional support accelerates pressure ulcer healing and reduces wound care intensity in nonmalnourished patients Nutrition 26(9): arginine, vitamin C and zinc in patients with pressure ulcers: a randomised controlled trial. Clinical Nutrition 24(6): 979-87 DH (2014) The NHS Outcomes Framework 2014/15. Available online: www.gov.uk (accessed on 29 June, 2016) Elia M (2000) Guidelines for Detection and Management of Malnutrition. Malnutrition Advisory Group (MAG), standing committee of BAPEN, Maidenhead Elia M, Russell CA (2009) Combating Malnutrition: recommendations for action. BAPEN, Redditch Flood A, Chung A Parker H, Kearns V, O’Sullivan (2014) The use of hand-grip strength as a predictor of nutrition status in hospital patients. Clin Nutr 33(1): 106-14 Langer G, Fink A (2014) Nutritional interventions for preventing and treating pressure ulcers (review) Cochrane Database of Systematic Reviews 6: CD003216 NICE (2012) Nutrition support in adults. O Revalidation Alert H aving read this article, reflect on: How you identify patients with pressure ulcers and a poor nutritional intake? How patient education can help people with providing the right nutrition Your knowledge of specific practical measures to increase nutritional intake. National Patient Safety Goals , health and medicine homework help

Then, upload the article to the new, free JCN revalidation e-portfolio as evidence of your continued learning: www.jcn.co.uk/revalidation Copyright of Journal of Community Nursing is the property of Wound Care People Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use. ISSN: 1981-8963 DOI: 10.5205/reuol.9881-87554-1-EDSM1011201607 Matos SDO, Souza APMA de, Aguiar ESS de et al. Pressure sore prevention: knowledge of formal… ORIGINAL ARTICLE PRESSURE SORE PREVENTION: KNOWLEDGE OF FORMAL CAREGIVERS OF INSTITUTIONALIZED ELDERLY PEOPLE PREVENÇÃO DE ÚLCERA POR PRESSÃO: SABERES DE CUIDADORES FORMAIS DE PESSOAS IDOSAS INSTITUCIONALIZADAS PREVENCIÓN DE ÚLCERA POR PRESIÓN: SABERES DE CUIDADORES FORMALES DE LOS ANCIANOS INSTITUCIONALIZADOS Suellen Duarte de Oliveira Matos1, Ana Paula Marques Andrade de Souza2, Elizabeth Souza Silva de Aguiar3, Mirian Alves da Silva4, Maria Júlia Guimarães Oliveira Soares 5, Simone Helena dos Santos Oliveira6 ABSTRACT Objective: to investigate knowledge of the elder’s caregivers about pressure ulcers (PU) and the necessary precautions to prevent them. Method: this is a cross-sectional study with quantitative approach, conducted with 51 caregivers of two long-stay institutions for elderly nursing in João Pessoa/PB, Brazil. The interview technique was used and the data were analyzed with descriptive statistics. Results: 96% of caregivers are women, 41% are 31-40 years-old and only 18% have formal education for elder’s care. Regarding the development of UP, 55% pointed to the lack of changing positions as a determining factor and as a means of prevention, 55% highlighted the body hydration. Conclusion: caregivers value preventive care, however, they need to improve the knowledge through capabilities that address the prevention of skin lesions of the elderly people, such as UP. Descriptors: Pressure Ulcer; Disease Prevention; Caregivers; Homes for the Aged. RESUMO Objetivo: investigar os saberes de cuidadores de idosos sobre úlcera por pressão (UP) e os cuidados necessários para preveni-las. Método: estudo transversal, de abordagem quantitativa, realizado com 51 cuidadores de idosos de duas instituições de longa permanência para idosos de João Pessoa/PB, Brasil. Empregou-se a técnica de entrevista e os dados foram analisados sob a estatística descritiva. Resultados: 96% dos cuidadores eram mulheres, 41% possuíam 31 a 40 anos e apenas 18% apresentava formação de Cuidador de idoso. National Patient Safety Goals , health and medicine homework help

Quanto ao desenvolvimento de UP, 55% apontaram a falta de mudança de decúbito como fator determinante e como forma de prevenção, 55% destacaram a hidratação corporal. Conclusão: os cuidadores valorizam os cuidados preventivos, no entanto, necessitam aprimorar os conhecimentos por meio de capacitações que abordem a prevenção de lesões na pele do idoso, como as UP. Descritores: Úlceras por Pressão; Prevenção de Doenças; Cuidadores; Instituição de Longa Permanência para Idosos. RESUMEN Objetivo: investigar los saberes de cuidadores de los ancianos acerca de las úlceras por presión (UPP) y las precauciones necesarias para prevenirlos. Método: estudio transversal con un enfoque cuantitativo, realizado con 51 cuidadores de dos instituciones de larga estancia para ancianos de João Pessoa/PB, Brasil. La técnica de la entrevista fue utilizada y los datos se analizaron con estadística descriptiva. Resultados: El 96% de los cuidadores eran mujeres, el 41% tenía 31-40 años y sólo el 18% tienen la formación del cuidador de anciano. En cuanto al desarrollo de UP, 55% señaló la falta de cambio de posiciones como un factor determinante y como medio para la prevención, el 55% destacó la hidratación del cuerpo. Conclusión: los médicos valoran la atención preventiva, sin embargo, que necesitan para mejorar el conocimiento a través de las capacidades que se ocupan de la prevención de lesiones en la piel de las personas mayores, tales como UP. Descriptores: Úlcera por Presión; Prevención de Enfermedades; Cuidadores; Hogares para Ancianos. 1 Nurse, Master student, Postgraduate Program of Nursing, Universidade Federal da Paraíba/PPGENF/UFPB. Scholarship of CAPES. João Pessoa (PB), Brazil. E-mail: suellen_321@hotmail.com; 2Nurse, Master professor, PhD student, Postgraduate Program of Nursing, Universidade Federal da Paraíba/PPGENF/UFPB. João Pessoa (PB), Brazil. E-mail: anapmasouza@yahoo.com.br; 3Nurse, Master professor, PhD student, Postgraduate Program of Nursing, Universidade Federal da Paraíba/PPGENF/UFPB, Scholarship of CAPES. João Pessoa (PB), Brazil. E-mail: elisouaguiar@hotmail.com; 4Nurse, PhD professor, Universidade Federal da Paraíba/UFPB. João Pessoa (PB), Brazil. E-mail: miads.enf@gmail.com; 5Nurse, PhD professor, Postgraduate Program of Nursing, Universidade Federal da Paraíba/PPGENF/UFPB. João Pessoa (PB), Brazil. E-mail: mmjulieg@gmail.com; 6Nurse, PhD professor, Health Technical School (ETS), Postgraduate Program of Nursing, Universidade Federal da Paraíba/PPGENF/UFPB. João Pessoa (PB), Brazil. E-mail: simonehsoliveira@hotmail.com English/Portuguese J Nurs UFPE on line., Recife, 10(11):3869-74, Nov., 2016 3869 ISSN: 1981-8963 Matos SDO, Souza APMA de, Aguiar ESS de et al. National Patient Safety Goals , health and medicine homework help

INTRODUCTION In view of the increasing number of elderly people in Brazil and around the world, resulting in enlargement of the top of the age pyramid, it is imperative to monitor the aging process in order to evaluate and to prepare the various segments of society to act for specific and qualified with this age group. The aging process involves a set of biopsychosocial factors that lead the elderly people to increased functional decline and risks of harm to health and the prevalence of chronic diseases that may cause some kind of disability, or dependence. This dependence is characterized as a state in which the elderly cannot perform their basic activities of daily life, requiring the help of other people.4,5 Due to limitations imposed by aging that cause changes in cognitive status and dependency in activities of daily living, some families seek to shelter the elderly in longinstitutions for the elders (ILPIs) because they do not to have people who is available to care for the dependent elder in the family environment. This institutionalization often occurs as an alternative to ensure the necessary care to this elder.3,1 In long-stay institutions this care is offered by a multidisciplinary team and formal caregivers who provide paid services and assist in meeting the needs of daily life of the elderly person. For the hiring of elderly caregivers, institutions must have minimum criteria for admission, such as the experience in the care of elderly people or course of caregiver of elders, since care for the dependent older people is not an easy task and requires dedication and knowledge, as there are elderly people with different levels of dependency and require continuous care.4 In senior care, the caregiver must have known that the aging process is accompanied by changes in both the cognitive and biological level, being especially marked by changes in the skin and underlying structures, where there is reduction in vascularization, dry skin and loss of muscle mass, resulting in greater prominence of bony structures that favor the occurrence of injuries, particularly pressure ulcers (PU).5 Thus, the fragility of the skin of the elderly people makes them vulnerable to PU and the associated decline in functional capacity, the risk of PU development is increased.6 The presence of lesions in the elders causes emotional overload and provide change in English/Portuguese J Nurs UFPE on line., Recife, 10(11):3869-74, Nov., 2016 DOI: 10.5205/reuol.9881-87554-1-EDSM1011201607 Pressure sore prevention: knowledge of formal… body image, pain, infection and high cost to the family for their treatment.7 According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance,8 the Pus are related to many extrinsic and intrinsic factors to the patient that contribute to the occurrence of tissue injury or may be related to other factors which role is not fully understood. National Patient Safety Goals , health and medicine homework help

In this context, the caregiver should identify elements that integrate the skin care of the elderly people, in order to keep them intact or that contributes to the recovery of integrity during institutionalization. It is noteworthy that the caregiver has a significant role in assisting the elder, but in some circumstances they may not be adequately trained for this function. In this sense, nursing should assist caregivers in the care provided and define the specific supportive care.5 Therefore, being in continuous contact with the elderly patient and helping with the care of their basic needs, caregivers constitute a link between the elder and the health team. It is urgent to reflect on the implications brought to the elderly people when the elderly caregivers are not trained nor have little preparation to work with them, for the technical realization in many situations, the caregiver may come to perform an action that causes damage and this fact could worsen the health status. And in the particular case of the elderly people’s skin integrity, the caregiver can contribute or not to the preservation of a healthy skin. Faced with the above, considering the PU as a component of the National Patient Safety Plan, to investigate the knowledge of elderly caregivers of ILPIs about UP and the ways to prevent them, it is a timely concern, given that is growing the number of elders in the institutionalization process, requiring general and specific care is essential to routine care developed by caregivers in these institutions. Thus, to promote the maintenance of a healthy skin during aging exempt further damage to their health. It has also shown to be relevant to trace this kind of knowledge, because depending on the preparation of caregivers, it may raise in the services the need to empower caregivers, thus contributing to the quality of services and reducing or preventing the occurrence of PU between elderly people. Considering the changes that occur in the elderly people due to the physiological process of aging and the risk of developing PU, we formulated to study the following question: Knowledge about PU? Do they know 3870 ISSN: 1981-8963 Matos SDO, Souza APMA de, Aguiar ESS de et al. how to care for the prevention of PU? What do elders’ caregivers know about pressure ulcers and the care to prevent it? Thus, the present study aims to: ● Investigate the elders’ caregivers of knowledge about pressure ulcers (PU) and the necessary precautions to prevent them. METHOD Cross-sectional study with a quantitative approach, carried out in two long-stay institutions for the elderly people (LTCF), in the city of João Pessoa, Paraíba, during the months of August and September, 2012. At the time of the survey we registered six-ILPI in the Municipal Elderly People Council, the choice of two institutions for convenience; they represented the largest number of elderly people and human resources. The institutions were philanthropic and received the elders who are 60 years-old, of both sexes. National Patient Safety Goals , health and medicine homework help

The study population consisted of 60 caregivers of seniors; those 51 caregivers agreed to participate and were included in the sample. Inclusion criteria were: to act as formal caregivers of seniors in the institution and to be in exercise of the function at the time of the survey. Exclusion criteria were: being on vacation or away from the exercise of elder caregiver role in the investigated institution. After informed consent to participate in the study by signing the free and informed consent, we continued with data collection by interview technique, and used a structured instrument elaborated by the researchers. This instrument underwent a pilot test for suitability and the variables addressed were: gender, age, education, factors that contribute to the development of PU; anatomic regions at greatest risk of developing PU; care to prevent PU. The data were organized in a database of Microsoft Excel®, following they were subjected to analysis of descriptive statistics. The results are presented by the concept map prepared using the Cmap Tools software, in version 6.01.9 English/Portuguese J Nurs UFPE on line., Recife, 10(11):3869-74, Nov., 2016 DOI: 10.5205/reuol.9881-87554-1-EDSM1011201607 Pressure sore prevention: knowledge of formal… The conceptual map is considered a graphic representation that stimulates the concepts of organization and unity between theory and practice; therefore, it is evaluative tool that enables knowledge organization promoting experiences that give rise to reflection, seeking understanding and processing information, thus facilitating the understanding.10 This study was approved the project by the Ethics Committee of Faculdade de Enfermagem Nova Esperança – FACENE by Protocol 92/12 and CAAE: 06529612.2.0000.5179, respecting the ethical aspects of research involving human subjects, recommended by Resolution 466/12 of the National Health Council.11 RESULTS The results showed among the subjects, 49 were women (96%), 21 (41%) were aged from 31 to 40 years-old, 18 (35%) referred having completed high school and only one complete higher education, 14 (27%) had technical course of nursing assistant and only nine (18%) said they had done the course of caregiver for the elderly people. Considering the working time as a caregiver of seniors, 31 people (61%) reported one to five years of experience in this area. The information related to knowledge of elderly caregivers on PU and care needed to prevent them is presented in the conceptual map (Figure 1). Regarding the factors that favor the development of PU in the elderly people, the responses of caregivers who received most featured were: lack of decubitus change (55%), diaper use (22%), moist skin (16%) and lack of oral and body hydration (14%). Regarding the anatomical regions of higher risk for the development of PU, there was a greater number of response for: scapular region (69%), ischial regions and calcaneal (61% each) and trochanter (47%) (Figure 1). National Patient Safety Goals , health and medicine homework help

As for the care needed listed by the caregivers for the prevention of PU, it was showed a higher citation to: body moisturizing (55%), use of support surfaces (24%) and changing positions (22%) (Figure 1). 3871 ISSN: 1981-8963 Matos SDO, Souza APMA de, Aguiar ESS de et al. DISCUSSION In this study 96% of the elders’ caregivers investigated from the institutions are female, corroborating for studies in the issue.12-3 This fact has historical, cultural, social and emotional roots, blaming the woman for family care, and assigned this function in different situations, such as the role of caregiver12, and in this case the occupation in a ILPI. Nowadays, another fact is related to greater female participation in the labor market. In general, the profile of caregivers is similar to the findings of other studies.12-5 As regards the existence of the course Elderly Care among those surveyed, there was a low percentage of caregivers with this formation in the ILPI investigated, it is still something to become a reality within ILPI of the country, given the strong government investment in education, especially in the last decade, the Elderly Care course is being offered free of charge, both as a training course as a technical. Concerning the topic PU, this study identified a lack of consistency between the respondents when asked about the factors that contribute to it and preventive measures, and it is notorious that they did not have a relation between causal factors and acting on these factors as a means of preventing PU, as examples, it was found that: although more than 50% of the sample the absence of decubitus change was chosen as a causal factor for PU, only 22% said the position change as a preventive measure; Likewise, 22% reported the use of diaper as a factor English/Portuguese J Nurs UFPE on line., Recife, 10(11):3869-74, Nov., 2016 DOI: 10.5205/reuol.9881-87554-1-EDSM1011201607 Pressure sore prevention: knowledge of formal… that contributes to the PU and only 6% mentioned changing clothes/diaper in order to prevent (Figure 1). Dissonance evident among caregivers about the PU and its prevention demonstrates the need for preparation of these caregivers in order to qualify them in skin care of the elder, especially in the prevention of PU. Therefore, considering the national protocol for the prevention of PU, proposed from the National Program for Patient Safety,16 the caregivers could implement some specific support care for PU, as work to not trigger injury when the implementation of daily care hygiene and comfort; identification of any changes in the skin that can be reported to health professionals; Elderly skin hydration; changing positions; moisture inspection of the skin and diapering/clothing; to check food acceptance; besides informing the elderly complaints. Finally, to enable caregivers for the exercise of basic care in preventing PU, it may be possible to minimize the morbidity implications and mortality brought about by these injuries, to reduce the burden on caregivers and healthcare professionals, given that when the PU is present it demands more time to care, increase spending on health and compromise the quality of life of the affected. It is essential to emphasize that nursing plays an important role in caring for the elderly because they identify vulnerability factors in the elderly, plan nursing care, in addition to guiding the support of care provided by the caregiver,5 therefore, nursing defines and controls these supportive care or basic that can be performed by caregivers in the routine. 3872 ISSN: 1981-8963 Matos SDO, Souza APMA de, Aguiar ESS de et al. National Patient Safety Goals , health and medicine homework help

Research conducted in ILPI showed a lack of knowledge necessary for the exercise of care as one of the difficulties in the daily routine of elderly caregivers, confirming the need for ongoing educational activities along the caregivers.12 As for the factors that favor the development of PU or risk factor, study in ILPI identified most frequently among elderly institutionalized to: chronic diseases, such as hypertension and stroke; bed rest; deficient nutritional status and pressure on bone prominences.7 As the Protocol for Pressure Ulcer Prevention of Brazil, drawn from the National Program for Patient Safety (PNSP), Ordinance No. 529 / 2013,13 maintaining the integrity of the skin of patients confined to bed, it is based on knowledge and applying relatively simple care measures. Most of the recommendations for skin assessment and preventive measures can be used universally, i.e., they are valid both for the pressure ulcer prevention (UPP) and for other skin injuries. The Protocol for Pressure Ulcer Prevention13 and guideline of EPUAP/NPUAP8 list several recommendations for the prevention of PU and, among these, we highlight some of the strong force of evidence as to inspect the skin on the areas of erythema; to avoid positioning the individual on a body surface that is flushed; to keep the skin clean and dry (using PH balanced product); do not massage or rub the skin vigorously that is at risk of pressure ulcers (such as the fragile skin of the elderly); to keep skin sanitized immediately after the episodes of incontinence; to protect the skin from exposure to excessive moisture; to apply emollients to moisturize dry skin; to develop an individualized plan of nutritional care and to monitor nutritional status; to promote daily and adequate fluid intake for hydration; reposition all individuals who are at risk of developing or who have already developed PU (unless contraindicated); do not use devices in the form of ring or loop; to raise their heels ensuring that these do not come into contact with the surface of the bed; to analyze the characteristics of foam mattresses used in the institution and to ensure that they are of high specificity, and ensuring that medical devices are properly sized and adjusted to prevent excessive pressure. The results of this study raises the responsibility of ILPIs to implement and standardize actions to prevent PU in routine care exercised by caregivers, since these spend more time close to the elderly in these institutions, representing the key link to care English/Portuguese J Nurs UFPE on line., Recife, 10(11):3869-74, Nov., 2016 DOI: 10.5205/reuol.9881-87554-1-EDSM1011201607 Pressure sore prevention: knowledge of formal… the elderly skin and to signal any change to the nursing staff and/or other health professionals. National Patient Safety Goals , health and medicine homework help

Thus, caregivers need to be able to maintain the skin integrity of the elderly, and thus for the prevention of skin lesions, such as PU; apart from that, the nursing is urged to guide and supervise the care of support that can be performed by caregivers in the prevention of PU. CONCLUSION The surveyed caregivers are not trained to assist in PU prevention among the elderly, as evidenced due to dissonance related to theme PU identified in the current study. Thus, these elderly caregivers need to improve their knowledge through training related to the prevention of skin lesions of the elderly, such as PU, in order to focus care covering from maintaining old skin integrity, preservation of functional capacity to the prevention of health problems. It is recommended that nurses with other health professionals of institutions aimed at educational strategies to educate caregivers of ILPIs in order to be their faithful collaborators in the fight against PU in the elderly, by adopting simple preventive measures, but in some services they are presented as innovative realities. REFERENCES 1. Marinho LM, Vieira MA, Costa SM, Andrade JMO. Grau de dependência de idosos residentes em instituições de longa permanência. Rev Gaúcha Enferm [Internet]. 2013 [cited 2016 Jan 15];34(1):104-11. Available from: http://www.seer.ufrgs.br/index.php/Revista Gauchade Enfermagem/article/view/25714/24514 2. Oliveira LPBA, Menezes MP. Representações de fragilidade para idosos no contexto da estratégia saúde da família. Texto contextoenferm [Internet]. 2011 [cited 2016 Jan 12];20(2):301-9. Available from: http://www.scielo.br/scielo.php?script=sciart text&pid=S0 104- 07072011000200012&lng=en 3. Clares JWB, Freitas MC, Paulino MHC. Sistematização da assistência de enfermagem ao idoso institucionalizado fundamentada em virginia henderson. Rev Rene [Internet]. 2013 [cited 2016 Jan 16];14(3):649-58. Available from: http://www.redalyc.org/pdf/3240/32 4027991019.pdf 4. Fuhrmanna AC, Bierhalsb CCBK, Santos NO, Paskulind LMG. The association between the functional incapacity of the older adult and 3873 ISSN: 1981-8963 Matos SDO, Souza APMA de, Aguiar ESS de et al. the family caregiver’s burden. Rev Gaúcha Enferm [Internet]. 2015 [cited 2016 Jan 17];36(1):14-20. Available from: http://www.scielo.br/pdf/rlae/v21n5/01041169-rlae-21-05-1096.pdf 5. Santos CT, Oliveira MC, Pereira AGS, Suzuki LM, Lucena AF. Pressure ulcer care quality indicator: analysis of medical records and incident report. Rev Gaúcha Enferm [Internet]. 2013 [cited 2016 Jan 12];34(1):1118. Available from: http://www.scielo.br/pdf/rgenf /v34n1/en_14.pdf 6. Aguiar ESS, Soares MJGO, Caliri MHL, Costa MML, Oliveira SHS. Avaliação da capacidade funcional de idosos associada ao risco de úlcera por pressão. Acta Paul Enferm [Internet]. 2012 [cited 2016 Jan 11];25(spe1):94-100. Available from: http://www.scielo.br/ scielo.php?script=sci_arttext&pid=S010321002012000800015&lng=en 7. Freitas MC, Medeiros ABF, Guedes MVC, Almeida PC, Galiza FT, Nogueira JM. Úlcera por pressão em idosos institucionalizados: análise da prevalência e fatores de risco. Rev Gaúcha Enferm [Internet]. 2011 Mar [cited 2016 Jan 11];32(1):143-50. Available from: http://www.scielo.br/scielo.php?script=sci_ar ttext&pid=S198314472011000100019&lng=en 8. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. National Patient Safety Goals , health and medicine homework help

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