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Case Scenarios: Putting Your Dressing Knowledge Into Practice

Selecting advanced wound care dressings is most effective when looking at the “whole” patient. If you are focusing only on the “hole” in the patient, you may not be enhancing the wound healing process as much as you had anticipated. In fact, you may be causing more harm to the wound without realizing it. Remember to always involve your patients in their treatment care plan, if possible. Your patients do not always share what is going on at home or economically . Let’s walk through a couple of case scenarios that may help you think outside the box when choosing a treatment plan for your patient.

Case Scenario #1: Chronic Pressure Ulcer – Stage 4

Your patient is a 47-year-old woman who has had a history of diabetes for the past 25 years, is a stroke survivor, and has congestive heart failure. She developed a stage 4 pressure ulcer following an above the knee amputation six months ago during her hospital stay. She lives at home with her daughter, who is a nurse, and also has home health care three days a week for dressing changes . Home health care is planned to last for only three weeks.

Wound etiology: Pressure ulcer, stage 4

Wound location: Coccyx

Thickness: Full

Size: 6×4×1.4cm

Undermining: 2–10 o’clock, 0.7cm

Wound tissue: 80% red granulation, 20% yellow fibrinous slough

Exudate: Heavy

Bioburden: Yes

What dressing order would you choose to benefit your patient most?

a. Cleanse wound with normal saline. Pat dry. Pack wound and undermining with calcium alginate. Cover with bordered foam three times a week. b. Cleanse wound with normal saline. Pat dry. Pack wound with wet-to-dry dressing twice daily. Cover with abdominal pads. Secure with paper tape. c. Cleanse wound with normal saline. Pat dry. Pack wound and undermining with silver alginate. Cover with bordered foam daily.

Answer: C. Due to date of onset, wound depth, exudate amount, and bioburden, an antimicrobial absorptive dressing is the best choice. The frequency is based on the exudate amount and the knowledge that the daughter can change the dressings on the days home health care is not available.

Case Scenario #2: Chronic Diabetic Neuropathic Foot Ulcer

Your patient is 85 years-old, lives alone and has no family. He has poor vision and limited mobility due to arthritis. He was diagnosed with type 2 diabetes two years ago. He is compliant with monthly diabetic checkups with his physician, and it was discovered that he had an ulcer at the plantar aspect of the right foot. Your patient has been treating the wound himself for three months by soaking his foot in Dreft laundry detergent. The patient has now been referred to the wound care center, where he will be seen weekly.

Wound etiology: Neuropathic ulcer, diabetic type 2

Wound location: Right foot, plantar

Size: 4.2×2.3×0.2cm

Wound tissue: Pink/red granulation 100%

Periwound: Hyperkeratotic

Exudate: Minimal to moderate

As the wound physician/nurse, what dressing order would you choose to benefit your patient most with his situation?

a. Cleanse foot wound with normal saline. Apply collagen particles to wound bed. Cover with bordered foam three times a week. b. Use silver hydrogel gauze dressing, foam, and a total contact cast once a week. c. Cleanse foot wound with normal saline. Apply silver foam dressing. Secure with gauze roll, tape, and one layer of retention dressing (above toes to 1 inch below knee). Change once a week.

Answer: C. The patient has arthritis and has no help at home. Selecting an advanced wound care dressing that has longer wear time is most beneficial for the patient and the wound healing process. Following up with the wound physician once a week will help with monitoring. In conclusion, not all patient scenarios are the same. Many factors play into developing a treatment care plan for your patients. Ask questions , educate, and tailor the plan of care. With thousands of dressings available, there are many options to make a better dressing selection that works for a patient’s specific needs. Educate yourself on dressing categories, indications, and wear time use. This way you can help your patients with wound healing to the best of your ability.

Note: The information provided herein is for informational purposes. Always refer to manufacturer information for Indications, Warnings and Precautions for a specific product.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.

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  • Open access
  • Published: 05 June 2023

How experienced wound care nurses conceptualize what to do in pressure injury management

  • Ye-Na Lee 1 &
  • Sung Ok Chang 2  

BMC Nursing volume  22 , Article number:  189 ( 2023 ) Cite this article

2161 Accesses

Metrics details

Conceptual understanding of the perceptions that wound care nurses use to determine how to manage pressure injuries may provide information for improving their pressure injury care competency. The aim of this study is to explore and describe the way wound care nurses experience and perceive pressure injury management.

A qualitative, phenomenographic approach, a method designed to explore the different ways in which people comprehend a phenomenon and develop a practical knowledge-based framework, was used in this study. Semi-structured interviews were used for data collection with twenty wound care nurses. All participants were female with a mean age of 38.0, mean total clinical experience of 15.2 years and mean clinical experience as wound care nurse of 7.7 years. The eight steps of qualitative data analysis for a phenomenographic study were employed to develop an understanding of participants’ experience of pressure injury management.

The analysis resulted in an assessment domain and an intervention domain, each containing three descriptive categories based on five identified conceptions. The categories were as follows: “comparison”, “consideration”, and “monitoring” in assessment, and “creation”, “conversation” and “judgement” in intervention.

Conclusions

This study has created a framework for understanding pressure injury management based on practical knowledge. This framework of the nurses’ pressure injury care reflected the need for an awareness of a harmonious approach to patients and wounds. There is a pattern of transcending a reliance on only theoretical knowledge, and this key factor in the framework should be considered when developing education programs and tools for improving nurse pressure injury care competency and patient safety.

Peer Review reports

The occurrence of pressure injuries (PIs) leads to economic losses caused by extended hospitalization and unnecessary increased medical costs for management [ 1 , 2 , 3 , 4 ]. There are also risks of complications, such as infections, which can increase when the condition is not properly treated through accurate and early assessment [ 5 , 6 ]. The risk of death from sepsis also increases when the condition is not treated [ 1 ]. Therefore, PIs are becoming increasingly recognized as a patient safety issue across the world [ 7 ]. As wound-related issues are taken more seriously, nurses capable of professional PI care are increasingly in demand.

To meet this need, wound care nurses have increased, and the scope and roles are expanding [ 8 , 9 ]. In addition, to enhance the overall PI care capacity of hospitals, PI education is emphasized to improve not only the competency of new wound care nurses but the competency of clinical nurses as a whole.

Clinical nurses have learned fundamental PI management, including anatomical and physiological knowledge related to skin and wounds and basic wound care according to their undergraduate curricula. After becoming clinical nurses they are provided with PI education both through continuing education and the PI guidelines formulated on the basis of evidence on the prevention and treatment of PI, in addition to regularly updated nursing intervention guidelines [ 10 ]. However, their continuing education has focused mostly on theoretical knowledge and been limited for developing nurses’ problem-solving skills and ability to apply knowledge in practice during actual PI care. Additionally, the clinical guidelines of PI care have primarily focused on the prevention rather than the treatment of PI, and the vast amount of content provided has hindered its practical use by clinical nurses as reference [ 11 ].

Although comprehensive knowledge as well as common sense are the basis of the decision-making process, it has been emphasized that practical knowledge is the most influential factor in wound management [ 12 ]. Several researchers have noted that, for nurses, when making decisions about wound management and expert decision-making in general, the hardest and most important part is the professional ability to focus on the most important aspects of the situation [ 13 , 14 , 15 ]. Such ability is nurses’ intuition of identifying the essence of the problematic situations, acquired through rich practical experiences [ 16 ]. Many previous studies have emphasized the importance of such practical knowledge in the management of PI [ 13 , 14 , 15 , 16 ].

However, according to previous studies, a clear gap exists between the guidelines and actual clinical practice, emphasizing the effectiveness of implementing clinical practical knowledge as a measure to reduce this gap [ 10 , 11 ]. However, many tools and educational programs used in current clinical practice are based on theoretical guidelines and modified to apply to a hospital or department basis, resulting in limitations to reflect individual clinical situations. For example, a meta-analysis of the Braden Scale revealed that it had moderate predictive validity with good sensitivity and low specificity in critically ill adult patients [ 17 ]. Therefore, the studies recommend either the further development and modification of this scale or the generation of a new tool of higher predictive power for use in ICU populations who have a higher risk of PI. Accurate and valid assessment of PI is important to identify high-risk patients and to provide appropriate PI management [ 17 ].

In order to be effective, PI education for new wound care nurses and clinical nurses, should implement such practical-knowledge-based education. Practical-knowledge-based education would allow nurses to independently assess the situation and make decisions on patients’ health issues based not only on their skills, but also their professional knowledge [ 18 ]. To achieve this requires a method of identifying the structure of PI management based on the individual experiences of wound care nurses and the resulting understandings they have acquired. This study was conducted to identify the clinical experiences of wound care nurses in PI assessment and intervention, the structure of PI assessment and intervention tasks developed by wound care nurses through their clinical experience, and the wound care nurses’ awareness of tasks related to PI assessment and intervention. In this way, the study can establish a practical knowledge set for incorporation into education and training systems.

Accordingly, the present study aimed to identify how experienced wound care nurses know what to do in PI management. The results also explored the experiences of wound care nurses in their clinical practice of PI assessment and intervention, which serves as the base resource that reflects rich clinical experience. In this way the study contributes to the development of efficient PI education and training applicable to nurses’ clinical practice, thereby reducing the gap between knowledge and clinical nursing.

This study applied phenomenography, which examines not the phenomenon itself, but the individual experiences of the phenomenon, and that focuses on and describes the difference between individuals in their experiences [ 19 ]. Phenomenography is used in the field of education to apply individual awareness of a phenomenon to the associated field of study [ 20 , 21 ]. The phenomenography method is used to identify the different qualitative experiences people have of a certain phenomenon [ 19 , 20 ]. This study by phenomenography focused on how different nurses viewed their awareness and how their awareness is related to the PI care process, which is in line with the focus on variation and how those variations are connected.

Participants

Participants were purposively selected to maximize variation and ensure data saturation. In a phenomenography study, the sample size should be between 10 and 30, and, in this study, saturation was confirmed in the data collected from twenty wound care nurses. The inclusion criteria were that the participants had completed the Fellowship of Korean Wound Academy and had been working as wound care nurses for 3 years or more. According to Benner’s theory, the first three years of work experience is the period during which one becomes accustomed to a duty, and one’s problem-solving efficiency improves [ 22 ]. All 20 participants were female with a mean age of 38.0 years (± 3.9 standard deviation [SD]). 14 were master’s graduates, and 6 were doctoral graduates. The mean extent of total clinical experience was 15.2 years (± 4.6 SD) and the mean extent of clinical experience as a wound care nurse was 7.7 years (± 3.6 SD).

Ethical consideration

This study was conducted after obtaining approval from the institutional review boards of Korea University Guro Hospital (No. KUGH17188-001). The study has been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards [ 23 ]. All interviewees were informed of the study purpose, methods and recording of interviews and were recruited only after they had agreed to participate and provided written consent. To ensure their voluntary participation, they were also informed of their right to withdraw their participation at any time during the study. Additionally, they were compensated for their participation as per ethical considerations. The names of the participants in the interview records were replaced with symbols and the interview records and transcripts were stored in a password-protected computer to ensure no unauthorized access to the data.

Data collection

The study data were collected from November 2017 to June 2018. The interview session duration was approximately one hour per participant and the questions posed were as follows: “How and based on what do you assess PIs in clinical practice?” and “How and based on what do you treat PIs in clinical practice?”.

Data analysis

The results of the phenomenography study are described by category and are comprised of an outcome space that indicates the relationship of the result with each category [ 20 ]. The conceptualization of experience is identified by determining categories and outcome spaces [ 19 , 20 , 24 ].

In this study, the interview data collected in Korean were translated into English and then analyzed. The translation used forward-translations and back-translation steps to achieve not only linguistic/literal equivalence but also cross-cultural and conceptual equivalence.

Next, the data analysis methods suggested by Dean [ 24 ] were applied: familiarization with data, highlighting and labeling, data comparison for similarities and differences, the grouping of similar data, coding data, explication of the essential similarities and differences in meaning, labeling each category, and describing logical relationships (Fig.  1 ).

figure 1

The Process of Data Analysis

Categories determination

In this study, one to six of the eight data analysis methods suggested by Dean [ 24 ] were used to determine the categories of wound management experience conceptualization by wound care nurses.

Composition of outcome space

The composition of the outcome space refers to the internal relationships and hierarchical levels within each category [ 24 ]. When applying this approach, to structure the outcome space researchers may use methods based on theories or academic perspectives in the relevant fields. In this study, researchers identified the categories comprising the analyzed experience conceptualization and suggested the relationships between them. The outcome space was determined through the analysis steps 7 and 8 of Dean’s data analysis methods (Fig.  1 ) [ 24 ].

Trustworthiness

To retain the study’s neutrality, the interviewer commenced without any intention of reaching a particular conclusion or proving a particular point and attempted to remain faithful to the interview data. Moreover, to minimize any bias or prejudice, a semi-structured questionnaire was used for the interviews to prevent the researcher’s bias from impacting the statements of the interviewees [ 25 ]. During the interview or analysis, any ambiguous or unclear parts of interviewee statements were clarified by follow-up questions. Two researchers analyzed the data after each interview and verified the meanings of the content and the categories [ 26 ]. The records of the interviews and results of the analyses were then sent to the interviewees via email or phone to ensure consistency between the descriptions written by the researchers in their analyses and the actual experiences of the study interviewees themselves [ 26 ].

Each perception of PI management is identified as assessment or intervention and discussed.

How experienced wound care nurses conceptualize what to do in PI assessment

Category a1. focusing on what caused the condition of the wound.

Participants emphasized that they need to identify the cause of the wound accurately. Accordingly, participants should distinguish between PIs and other conditions such as incontinence-associated dermatitis, skin laceration, and moisture-associated skin damage.

“An injury caused by friction is not considered a PI. Therefore, it is important to check the origin of an injury carefully to determine whether the injury site is actually impacted by pressure. In operation rooms, they occur in unusual sites, even sites lacking bone-prominence. This is why we learn the position of a patient in an operating room through reviewing the chart.” [Participant 13].

Category A2. Interpreting by the sequential application of theoretical and practical knowledge

Participants evaluate PIs by identifying wound characteristics using the classification system suggested by the guidelines or theory. If there is any confusion, the specific experiences the nurses have had of each stage are compared to the current case to make the evaluation. Such knowledge gained from experience of success or failure in PI management is practical knowledge.

“I learned that stage 2 involves dermis exposure and stage 3 involves fat. But sometimes it is hard to tell advanced Stage 2 from Stage 3 based on only such knowledge. What I do to distinguish stage 2 is to subtly scratch the injury with a blade. As dermis is of limited thickness and subcutaneous blood supply is low, in most cases the injury does not bleed. So, bleeding distinguishes between Stage 2 and 3.” [Participant 7].

Category A3. Comparing the risk of aggravation and healing potential

Participants also assess whether the wound bed is covered with slough or necrotic tissue, whether the surrounding skin is red, and whether the tissue is healthy. They evaluate PIs by considering advanced aspects of the condition, such as how long it will take to heal. They emphasized that the assessment should be made considering the risk of aggravation and the healing potential.

“I think we need to assess differently between superficial and deep wounds at Stage 2. This is important is because the target healing period is longer at deep Stage 2 than superficial stage 2, and this difference affects the direction and purpose of treatment. I assess the shape of the fat even within Stage 3. One form of fat has vesicles covered by a capsule like a peeled orange and the other form is loose in form but is not yet slough. The two cases would develop into different results, so they require different assessment.” [Participant 15].

Category A4. Identifying the possibility of improving the potential for healing

Participants assess PIs at the same stage differently, considering individual patient characteristics such as age, pre-existing diseases, skin color, and skin thickness by location. They said a PI assessment needs to include a patient-oriented assessment comprehensive in scope, including the patient’s diseases, nutritional status and needs.

“Even the same wound can have different results depending on patient characteristics such as age, and pre-existing diseases and conditions. This must be considered in the assessment as well. Accordingly, it may not be clinically correct to classify wounds as the same Stage 1 PI by simply assessing whether or not the wound is non-blanching erythema. Erythema affects different results based on the individual patient characteristics, and, therefore, different treatment methods should be considered.” [Participant 2].

Category A5. Monitoring within the healing time frame

Participants not only perform an early assessment but also continuously assesses and record the status of a PI whenever dressing the wound. This category reflects the need for continuous and repetitive observations and checking-up on the development of exudation or signs of infection at intervals to adjust treatment methods accordingly.

“Deep tissue injury (DTI) is hard to identify as those with an increased international normalized ratio (INR) have petechiae all over the body. It can be hard to tell whether there has been pressure on the site or not. So, when we wait and see how the condition develops, demarcation signs appear, it turns out to be DTI indeed. This is why DTI needs to be evaluated on a constant basis.” [Participant 10].

How experienced wound care nurses conceptualize what to do in PI interventions

Category i1. strengthen the recovery ability of skin.

Participants thoroughly consider how to improve support of the surface better and use products or instruments to control the temperature and humidity of the surrounding skin to improve tissue perfusion to recover damaged tissue. This category emphasizes efforts to improve the durability of the PI and the surrounding skin to let the skin naturally recover.

“If the skin around the wound is dry, I apply moisturizers to help the wound heal. Instead of focusing only on the wound, I first apply sufficient moisturizer to surrounding skin to address the dryness and then apply the foam or ointment to the wound.” [Participant 17].

Category I2. Creating an environment to maximize healing potential

Participants manage the hygiene of the patient and educate a caregiver or ward nurse about the importance of PI management. This category reflects the view that creating a proper therapeutic environment promotes healing. Moreover, the effort of medical staff and continuous support and care of other individuals are required for a good treatment result.

“You can’t just ask the caregiver to change the position. You must explain and show directly about the appropriate position change for the site of the PI, and the caregiver should be guided to check with his or her hand to confirm the pressure is not loaded to the PI site.” [Participant 1].

Category I3. Increasing positive signs of healing

When participants change the dressing, they assess the state of PI healing and expect positive signs, such as a reduced injury size or a decreased amount of exudation. This category is to ensure that the current treatment method yields positive outcomes and to maintain it or maximize the positive effects of fast healing.

“In Stage 2, re-epithelization is important. You must ensure the edge of the wound is not dry and is well covered. And if it is confirmed, you can expect a better outcome. Similarly, in Stage 1, the skin color returns to normal in the process of healing. I perform more frequent check-ups on the status of a PI at Stage 1 than at the other stages.” [Participant 9].

Category I4. Focusing on the interaction of dying cells with living cells

When choosing a treatment method to heal a wound, wound care nurses constantly think about priorities, while considering the impact on wound healing. In other words, participants constantly interact both with the cells regenerating within the injury and those dying. An integrated understanding of why some cells are alive and why some are dying helps the participants to promptly detect the occurrence of PI complications, such as infections, and prevent deterioration in advance through dressing, such as with antiseptics, antimicrobial medicines.

“Many nurses are concerned whether they can use povidone iodine, which is toxic to normal cells. I think that if there are any signs of infection, such as malodor and slough, they should be dealt with first using iodine. You have to pass the infection stage before you can move on to the proliferation stage. You need to calculate what the gain is and what the loss is” [Participant 18].

Category I5. Determining what I can and cannot do

Throughout treatment, participants adjust the care plan according to the monitoring results. When doing this, they need to properly determine the scope of their capability, thinking about what they can and cannot do as a wound care nurse including not only clinical decision-making but also privileging and credentialing. Proper judgment in this category can facilitate and accelerate the healing of PIs through an effective use of resources and collaboration.

“PI is healed by the combination of every clinician’s effort. PIs will not heal no matter how hard I attempt a good treatment if the patients are not well-nourished or have poor circulation. Therefore, we need to consult with a nutritionist and a cardiovascular center. A PI is not something that can be addressed by a wound care nurse alone.” [participant 5].

This study identifies the conceptualization of wound management experience by wound care nurses (Fig.  2 , Table 1 ). The five categories of PI assessment obtained from the conceptualization are hierarchically structured from level 1 to level 3: Comparison, Consideration, and Monitoring. The five categories of PI intervention obtained from the conceptualization are hierarchically structured from level 1 to level 3: Creation, Conversation, and Awareness of Limitation.

figure 2

Outcome Space of PI Management

The necessity of developing an effective framework for improving the competency of nurses in PI care is apparent. A training frame is a contained experience of how professional wound care nurses actually solve problems and is designed to improve the confidence of clinical nurses in realistic PI care situations. This study provides a conceptualized framework based on the flow of perceptions that have emerged from the PI care experiences of wound care nurses. The study of decision-making in wound management also identified ‘comparison’, ‘consideration’ and ‘monitoring’ through consistent evaluation. Note that these results are similar to the results obtained by this study for the assessment section. This study covers how to treat using such decision making and assessment, including flow diagrams. These findings improve practical knowledge and enhance and enrich the knowledge base for improving the performance of PI care.

When nursing a patient, nurses make many decisions. Expert nurses practice based on their know-how gained from experience, termed practical knowledge by scholars [ 19 , 22 ]. Consideration of the best knowledge to use in the nursing is a field of continuing interest [ 27 , 28 , 29 ]. Carper said that the knowledge used by nurses is practical knowledge derived from many resources, and that it is above empirical knowledge [ 30 ]. Benner said that expert nurses use their practical experiences as a source of knowledge to apply to other cases, and that this knowledge is not only used but also further developed each time [ 19 , 22 , 31 , 32 ]. In assessment especially, wound care nurses also make many decisions based on their empirical knowledge gained from clinical experience [ 33 ]. This is because guidelines do not consider the situations of individual patients [ 33 ]. Similarly, research has found that practice-based knowledge is the largest factor (57.5%) influencing nurses in wound care decisions [ 34 ]. Therefore, to obtain good wound care results, nurses can use their practical knowledge gained from experience to provide the appropriate ways of caring for individual patients. However, most education programs focus on guidelines and protocols. Although recently many educational programs have been augmented with hands-on lectures, they are still divided into theory and hands-on sessions, complicating the provision of integrated theoretical and practical knowledge.

In intervention, for a holistic approach to the care of chronic wounds, patient- and wound-centered concerns and follow-ups should be considered and adhered to [ 35 ]. In this study, it is said that ‘creation’ and ‘conversation’ should be managed by considering not only the wound, but also the condition of the patient and the surrounding environment, incorporating the need for integrated management, which has also been emphasized in previous studies. In addition, the framework derived in this study puts the part of ‘awareness of limitation’ at a higher level and integrates even aspects that are emphasized these days on individual competency improvement and surrounding collaboration.

Pressure ulcer care also should be managed by a holistic cycle (Fig.  1 ). The cognitive process for the management of PI suggested in the present study can achieve the healing of PI when the data is harmoniously and systematically collected and used together. First, the information is obtained through the ‘comparison’ step and then used in the ‘creation’ step. Next, evidence of healing is assessed in the ‘consideration’ step and a ‘conversation’ is had with the PI using the evidence. Finally, an ‘awareness of limitations’ is achieved based on the results of continuous ‘monitoring’.

A limitation of this study is that the approaches presented are sampled in only one country. In order to compensate for this, the sampling intentionally included varied participants, and the data was collected so as to achieve saturation. Also note that, the purpose of this study is to determine the nature and experiential structure of PI nursing by phenomenography rather than by obtaining a general description of the phenomenon.

The best way to improve PI management is to increase nurses’ practical competence in clinical settings. To achieve this, the practical knowledge, including perceptions of PI, proposed in this study should be thoroughly understood, with a special focus on the cognitive flow of PI management. A strength of the study was that this material provided rich data for which the participants reflected upon their lived experiences of the phenomenon of interest. The flow of the framework emphasizes to how to recognize and judge PI, rather than just theoretical PI knowledge. It effectively illuminates the actual process employed by nurses in managing PI, thereby bridging the gap between PI care knowledge and its practical application. By applying the cognitive process represented by this framework to the development of risk assessment and prevention strategies, which are currently lacking in existing guidelines [ 10 , 11 ], it becomes possible to create more practical and useful guidelines. Consequently, this framework suggests a more pragmatic and valuable direction for the development of guidelines, ultimately facilitating the improvement of PI care in accordance with the nursing environment and the individual characteristics of patients.

Accordingly, this study is useful in providing new information that can be used to achieve better PI nursing. Since the findings of this study shed a light on the practical knowledge required for effective PI nursing, they can provide useful information for the development of educational programs that can be flexibly applied to not only wound care nurses but also clinical nurses and nursing students. In addition, tools or education based on a practical knowledge-based framework effectively present the varied reasoning methods used by nurses for PI management in clinical practice, thereby improving and filling a void in understanding nurse interpretation and decision-making when managing patient PI.

Nurses can correctly infer how to treat PIs from the practical knowledge derived from their personal experiences. Accordingly, this study investigated the experiences of wound care nurses managing PI. Our results suggest a practical-knowledge-based frame of PI management in which assessment is conceptualized into comparison, consideration, and monitoring and intervention is conceptualized into creation, conversation, and awareness of limitations. We propose the necessity of conducting research to develop education based on the practical knowledge frame provided by this study.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to [individual privacy could be compromised] but are available from the corresponding author on reasonable request.

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Acknowledgements

This work was supported by a National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (No. NRF-2019R1A2C1086122) (No. NRF-2021R1G1A1091862).

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Lee, YN., Chang, S.O. How experienced wound care nurses conceptualize what to do in pressure injury management. BMC Nurs 22 , 189 (2023). https://doi.org/10.1186/s12912-023-01364-z

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  • Pressure injury
  • Phenomenography
  • Wound care nurse education

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Nursing Care Systematization: Case Study on Wound Care

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Research Article | DOI: https://doi.org/10.31579/2690-8808/107

  • Diego Henrique Alves Santos 1
  • Eliana da Silva Fernandes 2
  • Luciana Santos Longo 3
  • Rafaela da Cruz Leite 4
  • Liane Oliveira Souza Gomes 5*

1 Nurse. Graduated from the Nursing Course of the United Colleges of Research, Science and Health. Jequié-Bahia-Brazil.

2 Nurse. Graduated from the Nursing Course of the United Colleges of Research, Science and Health. Jequié-Bahia-Brazil.

3 Nurse. Graduated from the Nursing Course of the United Colleges of Research, Science and Health. Jequié-Bahia-Brazil.

4 Nurse. Graduated from the Nursing Course of the United Colleges of Research, Science and Health. Jequié-Bahia-Brazil.

5 Nurse. Graduated from the Nursing Course of the United Colleges of Research, Science and Health. Jequié-Bahia-Brazil.

*Corresponding Author: Liane Oliveira Souza, Nurse. Graduated from the Nursing Course of the United Colleges of Research, Science and Health. Jequié-Bahia-Brazil.

Citation: Liane Oliveira Souza,Diego Henrique Alves Santos, Eliana da Silva Fernandes, Luciana Santos Longo, Rafaela da Cruz Leite, Liane Oliveira Souza Gome (2022) Nursing Care Systematization: Case Study on Wound Care, Journal of Clinical Case Reports and Studies 3(9); DOI: 10.31579/2690-8808/107

Copyright: © 2022 Liane Oliveira Souza, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 06 May 2022 | Accepted: 15 September 2022 | Published: 07 October 2022

Keywords: healing; nursing care; nursing diagnosis; stomatherapy

The wound is defined as a rupture in the continuity of the skin, that is, an interruption of the tissue that, depending on its commitment, can affect the skin, mucosa or organs, being necessary to understand, also as an event of ethical and social responsibility among professionals of nursing. 

Wound care is a dynamic, complex process that requires special attention by the nursing professional, especially when referring to a chronic wound. In this context, it should be taken into account that chronic lesions evolve rapidly, are refractory to different types of treatments and result from predisposing conditions that make normal healing impossible. Adding the Systematization of Nursing Care (SAE) in the care of patients with wounds becomes of fundamental importance with the purpose of implementing and organizing care for them, making it possible to organize the nursing process.

The wound is defined as a rupture in the continuity of the skin, that is, an interruption of the tissue that, depending on its commitment, can affect the skin, mucosa or organs, being necessary to understand, also as an event of ethical and social responsibility among professionals. of nursing [1]. 

Wound care is a dynamic, complex process that requires special attention by the nursing professional, especially when referring to a chronic wound. In this context, it should be taken into account that chronic lesions evolve rapidly, are refractory to different types of treatments and result from predisposing conditions that make normal healing impossible [2]. Adding the Systematization of Nursing Care (SAE) in the care of patients with wounds becomes of fundamental importance with the purpose of implementing and organizing care for them, making it possible to organize the nursing process [3].

To report on the care of a patient with a chronic wound, at home, in the area covered by the Family Health Unit (USF), in a municipality in Bahia.

This is a descriptive study, of the case study type proposed during the Curricular component Supervised Internship I, offered in the ninth semester of the Undergraduate Nursing Course at the United Colleges of Research, Science and Health (FAPEC). This care was performed at home and at the Family Health Unit (USF) level, in order to investigate the health needs of this patient with a chronic wound, proposing to evaluate and provide care to her in an integral way, in the face of the problems of identified that interfered with the healing of his chronic wound. Several home visits were made to the patient and, when necessary, she was referred to the Family Health Unit (USF) by one of the authors, for reassessment by the health team or by the research authors. 

The case study was based on the resolution of the Federal Nursing Council (COFEN) No.: 358/2009, which provides for the Systematization of Nursing Care (SAE) and the implementation of the nursing process (NP) that proposes five steps : 1st stage – carrying out the data collection through the interview; 2nd stage – realization of the nursing diagnosis, which is the process of interpretation and grouping of data collected in the first stage, which culminates with the decision-making on the concepts of nursing diagnoses; 3rd stage – planning of nursing actions through support and education; 4th stage – execution and evaluation of the nursing actions planned for the patient and 5th stage – evaluation of nursing care, which is considered systematic and continuous in the possibility of changes in the patient's responses. The stages of the nursing process are interrelated [4]. 

After the conclusion of the data collection phase, the work of analyzing the collected information began. In order to arrive at the diagnoses, the defining characteristics and factors determined by the NANDA classification were based on adaptation to our environment according to the authors [3], as well as the authors' knowledge and experience in carrying out the implementation of the Systematization of Child Care Nursing (SAE).

At first, the nursing history was performed: Patient M.J.S. female, 61 years old, brown, single, catholic, housewife, coming from the outskirts of a municipality in Bahia. Type II Diabetes Mellitus and Systemic Arterial Hypertension (SAH). User of Metformin 850 (mg/day), Hydrochlorothiazide (25mg/day) and Lozartan (50mg/day). She reports not taking the medication correctly. The patient has an expression of crying, easy sad, oriented in time and space, in unsatisfactory hygienic conditions, cooperative, eupneic, afebrile, responding to verbal requests clearly, eating habits were also impaired and she was not using a low-sodium diet. She reports malaise, with walking deficits. On examination: she has a symmetrical chest. Globular abdomen. Afebrile (T: 36.8º), Hypertensive (BP: 180 x 80 mmHg).

She has an infected wound on the 1st toe of the Right Lower Limb (MID). Based on ethical issues, the patient signed the free and informed consent form authorizing the performance of the case study and later its publication, after clarification of the purpose of the research.

The results found led us to outline the following nursing diagnoses for this patient, according to NANDA: self-care deficit related to ambulation difficulties, acute pain related to redness and edema, risk of injury related to altered mobility due to mass disorder and vertigo, risk of impaired skin integrity, related to turgor and decreased elasticity, lack of knowledge about the risk factors for your illness, related to the incorrect use of medications, evidencing the persistent elevation of blood pressure and blood glucose, ineffective health maintenance, related to to ineffective individual coping, evidenced by the verbal report that he does not follow the drug treatment and tissues injured by mechanical factors (trauma and accident), risk of low self-esteem related to non-acceptance of the disease.

The identification of the main nursing diagnoses in this patient under study was important for the planning of nursing care, which involved the execution of goals, objectives and nursing prescriptions and, consequently, facilitated the evaluation of care, as it supported the desired actions. to achieve in the patient with the care provided with greater safety by the professional through an organized assistance, through the stages of the nursing process. The nursing prescriptions were mostly based on support and education actions, which shows us the coherence in the decision to guide the nursing process in patients with chronic pathologies, to whom they need guidance, mainly due to the incapacities that the disease produces, such as also by the level of education of this patient.

After the nursing prescriptions and later the implementation of nursing care, the authors noted the complication of the disease Diabetes Mellitus (DM) in the patient and consequently evolution of the worsening of the wound, where they carried out the referral for hospitalization. After several days of hospitalization and stabilization of glycemic and blood pressure levels, she returned to the Family Health Unit (USF), for continuity of treatment by the health team and the authors, once again implementing the Systematization of Nursing Care (SAE) for care.

This study made it possible to understand the importance of the use of the Systematization of Nursing Care (SAE) in the care of a wound patient, as well as the importance of monitoring the individual in their home context, in the face of a patient with incapacity for resolution. of their problems and thus understand the determinants that interfere in their treatment and thus be able to interfere in the process of caring for this wound, in order to successfully heal the wound.

  • Oak ESS. (2012). How to care for people with wounds: challenges for multidisciplinary practice. View at Publisher | View at Google Scholar
  • Candido LC. (2001). New approach to wound care. São Paulo: SENAC. View at Publisher | View at Google Scholar
  • Tanure MC. (2008). SAE – Systematization of Nursing Care: a practical guide. Rio de Janeiro: Guanabara Koogan. Cofen. (2009). Resolution No. 358. View at Publisher | View at Google Scholar
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Sternal wound management: a case study. Nursing grand rounds

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The complication of mediastinitis has important implications for nurses. This article describes the case of a man who developed a sternal wound infection following coronary artery bypass surgery. Nursing care is discussed and is summarized in care plans for the diagnoses Ineffective Breathing Pattern, Impaired Skin Integrity, and Ineffective Coping. Expert nursing care resulted in hospital discharge approximately two months after admission.

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Migrant suspect in laken riley murder accused of ‘seriously disfiguring’ nursing student as affidavit reveals grim details in case.

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The Venezuelan migrant charged with murdering Laken Riley allegedly beat her so brutally with an unidentified object that he disfigured her skull, according to new affidavits.

Jose Antonio Ibarra, 26, who faces multiple murder and assault charges, is not thought to have known the 22-year-old nursing student when he allegedly kidnapped and killed her as she went for a run on the University of Georgia campus Thursday.  

Her cause of death had only been given as blunt force trauma, with new charging documents accusing Ibarra of causing “great bodily harm with an object,” without specifying exactly what it was.

Murder victim Laken Riley.

But the suspect was also charged with aggravated battery for “seriously disfiguring her body … by disfiguring her skull,” according to the affidavits shared by Fox News .

Ibarra is also charged with preventing Riley “from making or completing a 911 call” with “intent to harm” when he allegedly snatched her during her run, the affidavit says.

He then dragged Riley’s body to a secluded area, the affidavit said in support of a charge for concealing the student’s death.

The suspect faces eight charges, including felony murder, false imprisonment and kidnapping and concealing the death of another. Authorities said there is no evidence he knew Riley.

Additional details about the type of object used, or exactly how she was killed, were not included in the affidavits, which were filed in Athens-Clarke County Superior Court.

The attack took place between 9 a.m. and 1 p.m. Thursday, according to the documents.

Accused killer Jose Antonio Ibarra.

Meanwhile, Athens-Clarke County DA Deborah Gonzalez announced Monday that she’s appointing a special prosecutor for the case, WANF-TV reported.

Gonzalez said she’s naming attorney Sheila Ross, whom she described as “a knowledgeable and well-respected trial attorney with the expertise ready to bring justice on behalf of Laken Riley.”

Last year, Ibarra twice slipped through the hands of law enforcement — and could have been deported after a bust in the Big Apple.

Police murder investigation in Georgia.

He was arrested in Queens on Aug. 31 and charged with endangering a child, but was released before immigration officials could file a request to ask local cops to hold him in custody, authorities said Monday.

Ibarra also was wanted on an arrest warrant in Georgia for blowing off a shoplifting court appearance in December, according to US Rep. Houston Gaines (R-Ga.).

“ICE confirmed what we already know: Jose Ibarra was in the country illegally,” Gaines  posted on X  Monday. “What the media hasn’t reported was that he was cited in Athens for shoplifting in Oct. — & there was a bench warrant for his arrest for failing to show in court.”

Follow along with The Post's coverage of Laken Riley's murder

  • Laken Riley’s suspected killer, Jose Ibarra, illegally entered US in 2022 — and was cut loose due to lack of detention space: report
  • Tributes to slain Ga. nursing student Laken Riley pour in as donations for scholarship in her name top $63K: ‘Would’ve saved so many lives’
  • Migrant charged in death of Georgia nursing student Laken Riley slipped through law enforcement’s hands twice
  • Laken Riley murder suspect Jose Ibarra lived it up in NYC after reportedly entering US illegally, social media posts appear to show
  • AP slammed for framing Laken Riley’s murder on dangers ‘female athletes’ face — not on migrant crimes
  • Migrant suspect in Laken Riley murder accused of ‘seriously disfiguring’ nursing student as affidavit reveals grim details in case

Ibarra entered the US illegally in El Paso , Texas, on Sept. 8, 2022, with his wife and her son seeking asylum, and was later released “for further processing,” ICE said.

He ended up in New York City, where he worked in food delivery and at an unnamed restaurant.

On Aug. 31, NYPD cops allegedly saw Ibarra riding a scooter with his 5-year-old stepson on board — with the child not wearing a helmet or restraints, according to police.

Accused killer Jose Antonio Ibarra.

Ibarra was charged with a felony and released.

On Oct. 27, the migrant was arrested at a Walmart in Athens, Georgia, and charged with shoplifting, an arrest report shows — only to miss a court appearance and have a warrant issued on Dec. 20, according to Gaines.

Riley, who transferred from the University of Georiga to the nearby Augusta University School of Nursing last year, is scheduled to be mourned at funeral services on Friday.

With Post wires

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Murder victim Laken Riley.

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  • v.76(3); 2023
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Nursing care directed to burned patients: a scoping review

Cuidados de enfermería dirigidos a pacientes quemados: una revisión de alcance, cuidados de enfermagem direcionados ao paciente queimado: uma revisão de escopo, pâmela cristine piltz costa.

I Universidade Federal do Paraná. Porto Velho, Rondônia, Brazil

Camila Schirmer Barbosa

Cristiano de oliveira ribeiro.

II Universidade Federal do Paraná. Curitiba, Paraná, Brazil

Luana Aparecida Alves da Silva

Luciana de alcantara nogueira, luciana puchalski kalinke, objectives:.

to identify in the literature and summarize nursing care in a hospital environment directed to patients who suffered burns.

a scoping review, according to the JBI Reviewers’ Manual recommendations, with a search in the MEDLINE, CINAHL, Web of Science, Scopus databases and in the Virtual Health Library portal, through articles published between 2016 and December 2021.

of the total 419 articles found, nine were selected for analysis. The main care measures identified were changing dressings and types of coverage, vital sign control, non-pharmacological techniques for pain relief and opioid reduction.

Conclusions:

the complexity of burn care requires constant updating by the nursing team. Keeping it prepared to carry out the best nursing care practices for burn patients will promote adequate care, patient recovery and reduction of possible harm.

identificar na literatura e sintetizar os cuidados de enfermagem em ambiente hospitalar direcionados aos pacientes que sofreram queimaduras.

Métodos:

revisão de escopo, segundo recomendações do JBI Reviewers’ Manual , com busca nas bases MEDLINE, CINAHL, Web of Science , Scopus e no portal Biblioteca Virtual em Saúde, através de artigos publicados entre 2016 e dezembro 2021.

Resultados:

do total 419 artigos encontrados, nove foram selecionados para análise. Os principais cuidados identificados foram troca de curativos e tipos de coberturas, controle dos sinais vitais, técnicas não farmacológicas para atenuação da dor e redução de opioides.

Conclusões:

a complexidade do cuidado em queimaduras requer constantes atualizações da equipe de enfermagem. Mantê-la preparada para a realização das melhores práticas de cuidado de enfermagem aos pacientes queimados promoverá a assistência adequada, recuperação do paciente e redução de possíveis danos.

identificar en la literatura y resumir los cuidados de enfermería en ambiente hospitalario dirigidos a pacientes que sufrieron quemaduras.

revisión de alcance, según las recomendaciones del JBI Reviewers’ Manual , con búsqueda en MEDLINE, CINAHL, Web of Science , Scopus y en el portal Biblioteca Virtual en Salud, a través de artículos publicados entre 2016 y diciembre de 2021.

del total de 419 artículos encontrados, nueve fueron seleccionados para el análisis. Las principales medidas de atención identificadas fueron cambio de apósitos y tipos de cobertura, control de signos vitales, técnicas no farmacológicas para el alivio del dolor y reducción de opioides.

Conclusiones:

la complejidad del cuidado de quemados exige una constante actualización por parte del equipo de enfermería. Mantenerlo preparado para llevar a cabo las mejores prácticas de atención de enfermería a los pacientes quemados promoverá la atención adecuada, la recuperación del paciente y la reducción de posibles daños.

INTRODUCTION

Defined as injuries to organic tissues, caused by chemical, physical and biological agents that compromise body tissues and cause cell death ( 1 ) , burns are considered the fourth most common type of trauma in the world ( 2 ) . In developing countries, such as Brazil, they are considered a public health problem and one of the main causes of mortality and partial or permanent disability ( 2 ) .

The World Health Organization (WHO) states that annually about 130,000 people are affected by some type of burn. In Brazil, it is estimated that one million burn accidents occur per year ( 3 ) , of which 10% seek hospital care and, of these, about 40,000 are hospitalized in a serious condition, requiring a quick, precise and adequate approach to define treatment ( 4 ) . It is noteworthy that 2 to 3% of these patients will die directly or indirectly ( 5 ) .

Northern Brazil is the one that least notifies the numbers for statistics, but it is the one that suffers most from fires in the country ( 6 ) . According to DATASUS, from June 2021 to June 2022, 4,487 hospital procedures were performed for the treatment of burns, corrosion and frostbite (ICD-10 T30) in the region. These data are relevant and show that, although most burned patients do not seek health services, and among those who do, there is underreporting, the number of consultations is still significant, which justifies the need for constant investment by the health system in prevention actions and appropriate management for this profile of patients ( 7 ) .

Despite advances in therapeutic procedures, burns in adult patients are considered a devastating aggression to human beings ( 8 ) , as they are responsible for physical and psychological sequel resulting from the emotional impact, causing changes in life and social limitations ( 9 ) . In this regard, with a view to minimizing damage, care should be initiated by assessing burned patients’ vital conditions and estimating the affected area. Then, injury assessment should be carried out, which aims to support and guide the actions to be taken ( 10 ) . Patients’ prognosis is directly associated with the extent of the affected body surface, the affected body region and injury depth ( 11 ) .

To describe the severity and prognosis of a burn, it is necessary to delineate issues such as the causal agent, depth and extent of a burned body surface area (BSA), which, once determined, will support the choice of treatment ( 12 ) . The “Rule of Nines” is often used to calculate the BSA, consisting of dividing the body surface of adults into multiples of nine, as it is more accurate in relation to body proportion and age ( 13 ) .

Knowing injury characteristics defines the initial treatment, however the therapeutic process results in long periods of hospitalization and rehabilitation treatments, with clinical and surgical procedures that impact patients’ quality of life. Therefore, the methods used for treatment must be directed by health services based on scientific evidence, aiming to minimize the sequelae caused and promote, when possible, patients’ total recovery ( 14 - 15 ) .

The nursing team is composed of professionals who work on the front line during health care provision. Therefore, the planning, monitoring and prevention of diseases secondary to burns are essential activities and aim at sustaining vital function, helping with rehabilitation, promoting quality of life and contributing to better clinical outcomes ( 16 ) . Moreover, these professionals must strive to minimize length of hospital stay, complications, sequel and the morbidity and mortality rate ( 17 ) .

Thus, knowing the necessary nursing care for adult patients who have suffered burns is essential to devise strategies and reorganize the execution of nursing work, in order to minimize sequelae and other effects. The lack of adequate and specific care can lead to greater complications and longer hospital stays, showing that qualified nursing teams are essential for the recovery of patients who have suffered burns ( 18 ) .

To identify in the literature and summarize the nursing care in a hospital environment directed to patients who suffered burns.

Ethical aspects

Ethical assessment was not necessary, since the material used is in the public domain and does not involve human beings.

Study design

This is a scoping review structured according to the recommendations of the international PRISMA guide ( 19 ) and the method proposed in the JBI ( 20 ) . This technique has been widely used in the area of health sciences, with the aim of synthesizing and disseminating the results of studies on a subject ( 21 ) . Its main objective is to map concepts that support a given area of knowledge, examine the extent, scope and nature of the investigation, summarize and disseminate research data and identify gaps in existing research ( 22 ) .

Search strategy and data source

In order to fulfill the steps of the proposed study, the objective of the study and the research question were listed, according to the PCC mnemonic combination: P (Population) - patients who suffered burns; C (Concept) - nursing care; C (Context) - hospital environment. Based on these definitions, the aim of the study was to identify in the literature and summarize nursing care in a hospital environment directed at adult patients who suffered burns, with the following guiding question: what is the nursing care in the hospital environment, directed to adult patients who suffered burns, available in the literature?

The descriptors and searches in the databases were selected from September to January 2022. It began with the search for the most used descriptors in searches, on the subject, contained in MEDLINE (via PubMed) and CINAHL (via EBSCO), followed by a broader search, using the same keywords and search terms in the databases Web of Science, Science Direct (via the Scopus platform), Cochrane Database of Systematic Reviews and the Virtual Health Library (VHL) portal.

The search strategy was developed together with a professional librarian from the Universidade Federal do Paraná (UFPR). The Health Sciences Descriptors and Medical Subject Headings (DeCS/MESH) were “Nursing”, “Nursing Care” and “Burns”, in English, Spanish and Portuguese. In the Scopus platform, the descriptors “Protocol” and “Validation Study” were included in the three languages.

The descriptors “Validation Study” and “Protocol” were included with the purpose of expanding the review, aiming at the search for scientific articles that bring validated care protocols, based on the best scientific evidence available and on local conditions, professional experience and client preferences.

Data collection took place between December 2021 and January 2022. Chart 1 fully presents the search strategies in each data source.

Data collection, organization and analysis

The complete articles were considered from the reading of titles by two independent researchers and, after reading abstracts, a pre-selection of those that fit the inclusion criteria of this review was carried out. In case of possible doubts or disagreements with the analysis of abstracts and/or their relevance to the study, there would be the inclusion of a third researcher.

Study refinement was based on eligibility criteria. Included were studies carried out in adult patients who suffered burns, with themes involving nursing, medicine and health, available in full for free, in Portuguese, English, Spanish. Studies that addressed patient care outside the hospital environment, pediatric patients, involving other areas of activity, theses, dissertations, reviews and non-indexed publications were excluded. The period from January 2016 to December 2021 was defined as a time frame, in order to cover current nursing care on the theme.

Data were extracted, organized and characterized in Microsoft Office Excel ® spreadsheets in the following order: authors, year of publication, place of publication and data source, objectives, methodology and related results. Subsequently, they were assessed for the level of evidence (LoE) and degree of recommendation, according to the Oxford Center Evidence-Based Medicine ( 23 ) . Then, they were analyzed using simple descriptive statistics (relative and absolute), presented in a chart and discussed with support from the literature. Data were obtained without disagreement between reviewers, who did not consider the inclusion of the third researcher or the need to contact the primary authors about the data.

Based on the analysis of 419 studies identified in the initial search, nine dealt with the topic addressed and corresponded to the final sample. Figure 1 specifies the results of the analysis steps, following the PRISMA Flow Diagram model ( 24 ) .

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Of the nine selected studies, one ( 25 ) was published in 2016 (11.1%), three ( 26 - 28 ) in 2017 (33.3%), three ( 29 - 31 ) in 2018 (33.3%), one ( 32 ) , in 2019 (11.1%) and one ( 33 ) , in 2020 (11.1%). The countries with the highest number of publications were the United States of America (USA) ( 25 , 28 , 31 - 32 ) , with four studies (44.4%), Brazil ( 26 , 30 ) , with two (22.2%), followed by the United Kingdom ( 29 ) , Spain ( 27 ) and Israel ( 33 ) , with one each (33.3%).

Regarding the methodology used by the studies, five (55.5%) are case studies ( 26 - 27 , 29 - 30 , 33 ) , two (22.2%), randomized clinical studies ( 28 , 32 ) , one (11.1%), descriptive ( 25 ) and one (11.1%), cross-sectional ( 31 ) . In the case of LoE, there was variation between 1B and 4, and the degree of recommendation, between A and C.

Analyzing LoE and degree of recommendation of selected studies, a higher frequency of LoE 3B ( 26 , 29 ) and 4 ( 27 , 30 ) is observed, with a total of two studies in each (44.4%) of the sample. Two studies show LoE 1B ( 28 , 33 ) (22.2%). With one study each (13.1%), two are levels 2B ( 25 ) and 2C ( 31 ) . Regarding the degree of recommendation, two are degree A ( 28 , 32 ) (22.2%), four are degree B ( 25 - 26 , 29 , 31 ) (44.4%) and three are degree C ( 27 , 30 , 33 ) (33.3%).

Regarding the objectives of the selected studies: one ( 30 ) (11.1%) study highlights the importance of implementing the Nursing Process; four ( 26 - 27 , 29 - 30 ) (44.4%) reinforce wound care and the importance of changing dressings and types of coverage for wound healing phases; two ( 25 , 28 ) (22.2%) emphasize pain control assessment through scales and analgesia; and two ( 31 , 33 ) (22.2%) emphasize non-pharmacological pain mitigation techniques to reduce the use of analgesia, such as music therapy, aromatherapy and relaxation techniques.

Among the results related to nursing care for patients who suffered burns, it was possible to observe that four ( 26 - 27 , 29 , 33 ) (44.4%) assessed care for burn injuries, three ( 25 , 28 , 30 ) (33.3%) analyze the interventions during the care of patients who suffered burns and two ( 31 - 32 ) (22.2%) demonstrate non-pharmacological techniques to reduce pain.

Nursing care directed to care for burn injuries reinforces that promoting the re-epithelialization of affected areas and minimizing the occurrence of scars is one of the main challenges faced by the nursing team ( 26 ) . Appropriate initial management of the burn, correct diagnosis, choice of ideal coverage, providing rapid healing ( 27 ) , in addition to avoiding constant dressing changes, allow for a correct approach to injury and provide greater comfort and dignity to patients ( 29 , 33 ) .

It is recommended, as nursing interventions, that the team directs care, aiming at the well-being and improvement of patients who have suffered burns. Nurses must identify nursing diagnoses, plan and implement their actions, resulting in quality care ( 30 ) . Reassessing their actions, especially those aimed at patients’ pain during the wound healing phases, applying pain assessment scales and seeking treatment strategies, can directly affect patients’ psychological, social and functional rehabilitation ( 25 , 32 ) .

Pain and anxiety are present throughout the burn healing phases, and inadequate pain control, especially in the acute phase, can have a greater negative outcome in patients ( 25 ) . Non-pharmacological forms of treatment ( 31 - 32 ) , such as pain reduction techniques, help to reduce anxiety, pain and use of opioids during burn dressing changes.

The studies that make up this review are those that contain information on the subject studied and present different nursing care aimed at adult patients who have suffered burns. Burns are harmful wounds and their characteristics are associated with the effects caused by injuries on body image and the implications of these in social circumstances. Associated with the complexity during the care provided to burned patients, nursing professionals require a set of skills to provide optimal and safe care.

Although burns mainly affect people in developing countries, such as Brazil, the USA and England were the precursor countries in the creation of services to improve treatment, called Burn Care Units (BTU), with the function of improving the indices in the care of patients who suffered burns ( 34 ) . This pioneering spirit may be related to the predominance of US publications among the studies in this review.

Although scientific and technological advances and the prognosis of burns have improved considerably in recent years, the success of care depends on the advancement of knowledge and the specific approach of health teams ( 35 ) . To this end, conducting research with primary source data is essential for discovering new techniques and conducts. However, this review demonstrates that the topic has been little explored in recent years, since the analyzed studies, in their predominance, adopt methodologies of bibliographic research, leaving the current literature scarce and generating gaps in the clinical decision-making processes and potential consequences for the population, the health system and the economy.

The prevalence of bibliographic studies may be related to lack of knowledge and ability of professionals to carry out research and apply it through evidence-based practice, revealing another gap. It should be noted that, even if there is a strong degree of recommendation in research for a given conduct, it is essential to analyze its suitability for a specific reality ( 36 ) .

With regard to nursing care for patients who have suffered burns, nursing actions must be comprehensive, since, in addition to wound healing, there are several needs in the process of recovery from burn injuries, such as psychobiological (oxygen therapy, hydration and nutrition, elimination, sleep and rest, body and oral hygiene, cutaneous-mucous and physical integrity, mobility, regulation, pain perception and therapy), psychosocial (communication and learning and gregarious) and psycho-spiritual (religious and ethical) needs. These care actions must be applied in the immediate, intermediate and late stages of burns, based on the care, educational and managerial contexts, using clinical reasoning for the elaboration and organization of nursing care ( 33 , 37 ) .

The importance of applying scales to assess the health status of patients who have suffered burns is observed. They are intended to measure the results of treatments and the impact of sequelae caused by burns on the daily life of this population, in addition to identifying whether patients require a more in-depth reassessment, treatment and management. For such an assessment, in addition to the pain control scale, the Burn Specific Health Scale (BSHS-R) can be used, which has the function of assessing the health status of patients who have suffered burns. The studies ( 31 , 38 ) that applied the scale reported improvement in the levels of physical and psychological function, in social relationships and in patients’ general health conditions after the rehabilitation intervention.

The use of dressing was also one of the nursing care found as a result. Due to their many benefits, dressings are considered a widely used measure in injuries of burn patients. In addition to preventing external infections and ensuring local temperature control, they contribute to absorption of fluids released by the wound and have a specific coverage area according to the injury’s aspect ( 39 ) .

In order to carry out better care practices for patients who have suffered burns, the nursing team must be prepared and updated on the subject. Therefore, having extensive knowledge about the physiognomy of injuries caused by burns helps in decision-making and in the elaboration of an intervention plan that promotes patient recovery, reducing possible damages, since the variability of treatment of an injury may be related, among others, to lack of training, professionals’ attitude and discontinuity of care ( 30 , 40 ) .

Among the various care provided by the nursing team to patients who have suffered burns, the most frequent are changing dressings, as they cause daily and significant pain and discomfort to patients ( 37 ) . Different types of dressings are available on the market, however, among the selected studies, it was shown that the safe and effective use of bromelain-based enzymatic debridement agents, beyond the recommended and suggested 48 hours, has satisfactory success rates in the injuries of patients who have suffered burns, being considered an effective treatment modality, including burns of late presentation and chronic wounds.

The choice of dressing and wound care cannot be an automatic procedure, but a ‘scientific exercise’, in which nurses must act consciously in order to apply measures that can facilitate the healing process. Therefore, in order to define the best type of coverage, a careful analysis of wound characteristics, patients’ clinical conditions and cost/benefit ratio must be taken into account ( 33 , 38 , 41 ) .

Of the analyzed studies, pain stood out as one of the main symptoms to be managed by nursing care for patients who suffered burns. Patients’ pain has a significant impact during their treatment, therefore, it is necessary to manage it properly, due to the biological, emotional and/or social consequences that it may have ( 42 ) .

Patients who have suffered burns experience intense pain during and after surgical and non-surgical interventions. The use of drugs, such as opioid analgesics, is the main and most effective form of pain management ( 43 ) . Opposing this result, studies ( 32 , 44 ) show that the use of non-pharmacological techniques to reduce pain, such as music therapy, aromatherapy and relaxation techniques, will demonstrate significant results after their application. The authors pointed out that, after using these methods, a reduction in the use of opioids was also observed, so that nursing professionals can provide these interventions, helping to reduce pain before performing painful procedures.

Study limitations

As a limitation, we highlight the non-inclusion of manuals, theses, dissertations and legislation from other countries. As this review study only addressed studies published from 2016 to December 2021, it may have restricted relevant articles, becoming a limitation in the survey of potentially important studies from a clinical point of view, despite the insistent search for data that corroborate with the best selection criteria in the databases and studies of several countries. Therefore, there is a need to develop studies with greater methodological impact, highlighting the need to develop more expressive research in the study area.

Contributions to nursing, health or public policy

Identifying the care inherent to patients who have suffered burns is important to list methods and reorient the execution of nursing work, in order to minimize sequelae and their consequences, as they directly reflect on patient safety and quality of care, in addition to cost reduction and patient morbidity and mortality.

CONCLUSIONS

Nursing care for adult patients who suffered burns identified in this review began with an assessment of their needs, given that, in order to base the implementation of best care practices, the nursing team must be prepared and updated on the subject. The complexity of care in this area requires constant updates from the team, therefore, it is necessary to maintain the permanent education routine to adapt the training of nursing professionals to the reality and use of products and services.

Having extensive knowledge about the pathophysiology of injuries and healing helps in decision-making and in the elaboration of an intervention plan that promotes patient recovery, reducing possible damages. Also, care related to pain control, wound cleaning, dressing changes and best nursing practices was evidenced, with safety promotion and training for updating.

From study analysis, it is observed that nursing assistance in the care process plays a fundamental role and that the team must have a specific and standardized approach to nursing care in pain relief and control and in the early detection of complications. In this way, it is expected that this study will help in the dissemination of the best evidence regarding nursing care for patients who have suffered burns, awakening interest in new productions, in order to address other phases of the nursing process, such as nursing diagnoses and nurses’ exclusive attributions and with a greater degree of academic expressiveness.

This study was funded by Notice 28/2019 - CAPES/COFEN.

EDITOR IN CHIEF: Dulce Barbosa

ASSOCIATE EDITOR: Luís Carlos Lopes-Júnior

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