Skin inspection for evaluating the presence of risk indicators to developing pressure ulcers

Abstract

Objective The skin of patients with multisystem trauma or spinal cord injury was inspected in order to evaluate the presence of indicators of risk for pressure ulcer development associated with the Nursing Outcomes Classification (NOC) descriptor 'Tissue Integrity: Skin and Mucosa'. Design and setting A cross-sectional descriptive study performed in a tertiary referral hospital integrated into the public health network of Fortaleza, Ceará state, Brazil. Subjects Forty-nine patients with multisystem trauma or spinal cord injury. Results Most participants were young men with multisystem trauma. The majority used pressure redistribution devices; the most common was a pyramidal mattress. Among NOC indicators for tissue integrity, texture showed the most change, followed by tissue temperature. The sacral region showed the greatest change in colour and temperature, and the scapulas showed the greatest change in temperature. Seventy-five percent of subjects had a final score of 5:5, indicating non-compromised skin. Conclusion Classification parameters were developed based on NOC indicators and their applicability in our patients was verified. Use of the NOC skin integrity outcomes may be an effective method for identifying risk indicators for pressure ulcer development.