Abstract
Although pressure injury (PI) is preventable, the number of patients developing this type of injury is still high. In this prospective cohort study, we aimed to assess whether high risk for undernutrition was a risk factor for PI in 1937 patients aged ≥18 at six hospitals in Sao Paulo, Brazil. Patients' risk for undernutrition was assessed using three unique screening tools. Risk for PI was assessed using the Braden Scale. Data were analysed using Poisson regression with robust variance (95% CI, P ≤ .05). While 57.1% of patients were at risk for undernutrition in the Nutritional Risk Screening (NRS 2002), only 36.8% and 2.6% were at risk in the Braden Scale Nutrition Subscale (BSNS) and Subjective Global Assessment of Nutritional Status (SGANS), respectively. The cumulative incidence rate was 5.9%. Of those who developed PI, 91.2%, 56.2%, and 18.4% were at risk for undernutrition in the NRS 2002, BSNS, and SGANS scales, respectively. We found a significantly higher risk for PI in patients who were at risk for undernutrition compared with those who were not at risk, supporting previous evidence about the role of undernutrition as a key risk factor for PI in hospitalised patients.
Keywords: nursing, nutritional screening, pressure injury, risk factors
1. INTRODUCTION
Pressure injury (PI) is still prevalent despite the major developments observed in health care technology, materials, and procedures in recent years. Up to 2016, PI was defined by the National Pressure Ulcer Advisory Panel (NPUAP) in the USA, the European Pressure Ulcer Advisory, and the Pan Pacific Pressure Injury Alliance as being a localised injury to the skin and/or underlying tissues or structures, usually above a bony prominence, resulting from isolated pressure or pressure combined with shear and/or friction. 1 In April 2016, the NPUAP established changes and updates to the definition and classification of the different levels of PIs. 2 PI is currently defined as a localised damage to the skin and/or soft underlying tissues, usually above a bony prominence, or related to the use of medical equipment or other materials. Mapping the incidence and prevalence rates of PI and its risk factors using this new classification system is important to allow for the establishment of appropriate and effective interdisciplinary actions aimed at preventing or treating PI.3, 4
In previous studies conducted in Brazil, the number of hospitalised patients who developed PI varied widely both in relation to the patients' profile and the health care settings – from 11.0% to 30.9% in intensive care units,5, 6, 7, 8 from 13.6% to 31.4% in surgical/clinical units, 9 and 13.4% in neurological units. 10 In nursing homes, the incidence of PI can be much higher – 39.4%. 11 It has been shown that about half of hospitalised patients develop undernutrition during hospitalisation, with severe undernutrition affecting approximately 12% to 15% of patients.12, 13 In a study conducted in 22 hospitals and 29 long‐term care homes in Germany involving 4067 and 2393 individuals, respectively, it was found a significant positive association between undernutrition and risk for PI. 14 As undernutrition is a key risk factor for PI, calorie and protein intake should be adequately, periodically, and closely monitored, with nutrition risk assessments conducted regularly, and undernutrition addressed effectively. As nutritional status may become poor after hospitalisation, identifying patients who are at risk for undernutrition should be common practice as a mean to prevent and treat PI.12, 13, 14, 15
Although a link exists between undernutrition and PI, the exact mechanisms involved in such association have not yet been fully established. 16 In a previous Cochrane review published in 2003, it was demonstrated that enteral and parenteral nutrition appear to be effective preventing the incidence of PI; however, high study heterogeneity hindered the establishment of a direct association between nutritional state and PI. 17 In another meta‐analysis published in 2005, it was found that the use of enteral nutritional supplementation in patients with high risk for undernutrition was linked to a significant reduction in the onset of PI. 18
In line with both the American Dietetic Association and the Brazilian Society of Enteral and Parenteral Nutrition, conducting periodical nutritional screenings can help identify those who are at a high risk for poor diet and undernutrition.19, 20 Nutritional screening can be conducted not only by a nutritionist, but also by other health professionals, as long as they are adequately trained for such a task. 21 Several nutritional screening tools have been previously developed and/or adapted and validated for use in Brazil, such as the Subjective Global Assessment of Nutritional Status (SGANS) scale and the Nutritional Risk Screening (NRS 2002). 22 However, there is a paucity of research assessing the potential role of nutrition as a risk factor for PI in Brazil. This study aimed to explore whether hospitalised patients with high risk for undernutrition have a high risk for the incidence of PI.
2. METHOD
2.1. Study design
This was a prospective cohort study conducted in six hospitals located in the city of Sao Paulo, Brazil, from April to September 2013.
2.2. Settings
Hospitals were selected from a database of health care institutions from the Brazilian Ministry of Health. This selection process was conducted in two stages. First, a list of all the hospitals located in the city of Sao Paulo was compiled, except for paediatric and psychiatric institutions. From that, 42 large‐ and medium‐sized hospitals were selected based on the inclusion criteria (described later). Second, the 42 selected institutions were randomised using a specialised software (www.random.com), from which six institutions were selected. The randomisation strategy considered a diverse number of beds, São Paulo region (North, South, West, East, and Centre) and the type of hospital (Specialised vs General).
2.3. Study participants
The study population included female and male adults (aged ≥18) who were being cared for at clinical wards or intensive care units at the time of the study, who had agreed to take part in the study, or a consultee agreed on their behalf. Patients with PI at admission were not excluded because of the possibility and risk of developing new PI. Current PI at admission were documented and not considered for the incidence analysis.
2.4. Procedure
Data were collected by nursing students who were at the fourth year of their undergraduate training. Students were selected via written test and focus group discussions about research knowledge and skills. After that, the selected students undertook a 40‐hour training programme about theoretical and practical aspects of research and ethics. Students had the opportunity to practice, under supervision, the application of the study questionnaires with patients at the hospital [hospital name blinded for peer review].
2.5. Measures and outcomes
2.5.1. Sociodemographic information
Sociodemographic information includes sex, age, clinical characteristics [length of hospital stay (in days), number of comorbidities (diabetes and hypertension), presence of unhealthy behaviours (tobacco smoking and alcohol consumption), and type of treatment (clinical vs surgical)].
2.5.2. The Braden scale
This scale measures the risk for, and severity of, PI. This tool is also useful to estimate the strongest risk factors for the development of PI. This scale was created in 1989 23 and was translated and adapted to the Brazilian context in 1999. 24 The scale is composed of six subscales – sensorial perception, humidity, activity, mobility, nutrition, and shear friction. Each subscale generates 1 to 4 points, except for shear and friction which generates 1 to 3 points. The total score varies from 6 to 23 points, of which 19 to 23 mean no risk, 15 to 18 mean low risk, 13 and 14 mean moderate risk, 10 to 12 mean high risk, and ≤9 mean very high risk. 25 In the present study, the Braden scale (risk assessment for PI) was applied at the moment of hospital admission or up to 48 hours after the hospital admission. After that, the patient's risk for PI was re‐evaluated at every 48 hours.
2.5.3. Braden Scale Nutrition Subscale
This scale is commonly used to screen for undernutrition as a risk factor for PI. It evaluates the patient's ingestion of nutrients (excellent, adequate, probably inadequate, and completely inadequate)26, 27 using a 1‐ to 4‐point system, of which 1 and 2 points mean poor nutrition and probable risk for PI due to probable undernutrition. In the present study, participants were assessed at the hospital admission and then once a week after that, until the hospital discharge or eventual death.
2.5.4. Subjective Global Assessment of Nutritional Status
This tool is considered a gold‐standard measure of nutritional status. It was first developed by Detsky et al 28 in the 1980s and considers both the patients' history and their clinical characteristics. The scoring system includes history of weight changes, food intake, gastrointestinal symptoms, and changes in the functional capacity for carrying out activities of daily living. The physical exam is conducted to detect signs of undernutrition, such as loss of subcutaneous fat and muscle mass, and sacral and extremity oedema. The final scores vary from low risk (<17 points), moderate undernutrition (17 to 22 points), or severe undernutrition (≥23). 22 In the present study, participants were assessed at the hospital admission and then once a week after that, until the hospital discharge or eventual death. Patients who were classified as having moderate or severe undernutrition were considered as being at nutritional risk.
2.5.5. Nutritional Risk Screening
This scale was primarily created to detect the presence of nutritional risk in hospitalised individuals. 29 It includes questions related to the individual Body Mass Index (BMI = weight / height x height), unintentional weight loss in the previous 3 months, reduction in food intake, stress related to the health condition, and aged above 70 years. The NRS 2002 can be used with adults and older adults within the hospital environment who are undergoing treatment for any health condition, being this either clinical or surgical. In older adults, the final scores are purposively increased as people's nutritional status tends to get poorer with age. 22 Based on the total scores, patients are classified as being without risk, having low risk, moderate risk, or high risk. 30 In the present study, participants were assessed at the hospital admission and then once a week after that, until the hospital discharge or eventual death. Patients who had low, moderate, or high risk were classified as being at risk for undernutrition.
2.6. Ethics
This study was approved both by the Research Ethics Committee of the hospital [hospital name and approval number blinded for peer review] and the hospital [hospital name and approval number blinded for peer review]. The study was also approved by the Director of each of the participating centres. All study participants understood, agreed, and signed consent forms. When participant was unable to consent, consultees (usually a family member) agreed on the individual's behalf. The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in approval by the institution's human research review committee.
2.7. Data analysis
The data collected were first digitalised and uploaded onto a spreadsheet using the Microsoft Excel® 2000 and were then analysed using Stata® 11.0. Descriptive statistics, including measurement of central tendency (frequency, medium, median, and range), were calculated to describe the sociodemographic and clinical characteristics of participants. To identify the variables predicting the incidence of PI, Poisson regression with robust variance was used. Relative Risks were calculated for each variable included in the model. Finally, Poisson regression was used to estimate which of the variables (risk scores) were more strongly associated with the PI incidence. Statistical analyses were conducted using a 95% confidence interval, with significance established at P ≤ .05.
3. RESULTS
The study population was composed of female and male adults and older adults who were admitted to surgical wards, clinical wards, or intensive care units of six hospitals (n = 2594). However, 657 people were excluded due to a number of reasons: 476 were discharged before the follow‐up period of the study (48 hours); 159 had been transferred from another hospital along with inconsistent clinical records; 22 did not have information about the discharge date; and one participant asked to be removed from the study. The final study sample therefore consisted of 1937 individuals.
As shown in Table 1, most participants were women (55.5%), aged between 18 and 103 years old (mean = 59.35; SD = 20.6). Approximately 12% (n = 237) were tobacco smokers and 18.5% (n = 352) drunk alcohol regularly. The mean length of stay in hospital was 6.8 days, 60.8% (n = 1178) stayed for up to 5 days, 21.5% (n = 416) from 6 to 10 days, 9.4% (n = 182) from 11 to 15 days, and 8.3% (n = 160) above 15 days. With regards to the type of treatment, 1193 (61.6%) were receiving clinical treatment, 21.7% (n = 414) had diabetes, and 45.2% (n = 817) had hypertension. The Braden scale (risk assessment for PI) indicated that 32.7% were at risk for the development of PI.
TABLE 1.
Sociodemographic and clinical characteristics
| Variables | n | % |
|---|---|---|
| Sociodemographic characteristics | ||
| Age (years) | ||
| ≥60 | 966 | 49.9 |
| 61‐80 | 608 | 31.4 |
| >80 | 363 | 18.7 |
| Sex | ||
| Female | 1075 | 55.5 |
| Male | 862 | 44.5 |
| Clinical/health behaviour characteristics | ||
| Smoking | 237 | 12.4 |
| Alcohol consumption | 352 | 18.5 |
| Diabetes | 414 | 21.7 |
| Hypertension | 817 | 45.2 |
| Length of hospital stay (days) | ||
| ≥5 | 1178 | 60.8 |
| 6‐10 | 416 | 21.5 |
| 11‐15 | 182 | 9.4 |
| ≥15 | 160 | 8.3 |
| Type of treatment | ||
| Surgical | 744 | 38.4 |
| Clinical | 1193 | 61.6 |
| Hospital unit | ||
| Clinical/surgical ward | 1877 | 96.9 |
| Intensive care unit | 60 | 3.1 |
| Risk assessment for PI (Braden scale) | ||
| No risk | 1304 | 67.3 |
| Low risk | 416 | 21.5 |
| Moderate risk | 86 | 4.4 |
| High risk | 103 | 5.3 |
| Very high risk | 28 | 1.45 |
As shown in Table 2, with regards to risk for undernutrition in relation to the BMI, 12.9% (n = 250) were underweight, 24.2% were overweight (n = 468), and 22.3% (n = 432) were obese. In relation to the SGANS scale, only 2.6% (n = 2.6) had moderate undernutrition and 0.5% (n = 9) had severe undernutrition. The NRS 2002 indicated that 57% (n = 1108) were at risk for undernutrition, of whom 7.3% (n = 140) were at low risk, 20.5% (n = 398) were at moderate risk, and 29.4% (n = 569) were at high risk. The outcomes of the Braden Scale Nutrition Subscale (BSNS) indicated that 36.5% (n = 707) were at risk for undernutrition, of which 8.0% (n = 155) had probable inadequate diet and 28.8% (n = 559) had completely inadequate diet. A total of 114 people developed PI during their hospital stay, representing a cumulative incidence rate of 5.9%.
TABLE 2.
Nutritional risk profile
| Variables | n | % |
|---|---|---|
| Body mass index | ||
| Eutrophic | 758 | 39.1 |
| Underweight | 250 | 12.9 |
| Overweight | 468 | 24.2 |
| Obese | 432 | 22.3 |
| Subjective Global Assessment Nutritional Status (SGANS) | ||
| Low risk | 1878 | 96.9 |
| Moderate undernutrition | 50 | 2.6 |
| Severe undernutrition | 9 | 0.5 |
| Nutritional Risk Screening 2002 (NRS 2002) | ||
| Without risk | 830 | 42.8 |
| Low risk | 140 | 7.3 |
| Moderate risk | 398 | 20.5 |
| High risk | 569 | 29.4 |
| Braden Scale Nutrition Subscale (BSNS) | ||
| Excellent | 516 | 26.7 |
| Adequate | 707 | 36.5 |
| Probably inadequate | 155 | 8.0 |
| Completely inadequate | 559 | 28.8 |
As shown in Table 3, of all patients who developed PI during their hospital stay (n = 114), 91.2% (n = 104) were detected as being at risk for undernutrition in the NRS 2002 scale; 18.42% (n = 21) in the SGANS scale, and 56.2% (n = 64) in the BSNS. Those who were at risk for undernutrition in the BSNS (56.2%) and the NRS 2002 (91.2%) were significantly at a higher risk for PI compared with those who were not at risk for undernutrition within these scales (43.8% and 8.8%, respectively).
TABLE 3.
Patients who developed pressure injury and who did not develop pressure injury according to their nutritional risk profile (n = 1937)
| Scales | Developed pressure injury | Did not develop pressure injury | Total | ||
|---|---|---|---|---|---|
| Braden Scale Nutrition Subscale (BSNS) | n | % | n | % | n (%) |
| Completely inadequate | 15 | 13.2 | 140 | 7.7 | 155 (8.9%) |
| Probably inadequate | 49 | 43.0 | 510 | 28.0 | 559 (28.9%) |
| Adequate | 39 | 34.2 | 668 | 36.6 | 707 (36.5%) |
| Excellent | 11 | 9.6 | 505 | 27.7 | 516 (26.7%) |
| Subjective Global Assessment of Nutritional Status (GANS) | |||||
| Low risk | 93 | 81.6 | 1785 | 97.9 | 1878 (96.9%) |
| Moderate undernutrition | 15 | 13.2 | 35 | 1.9 | 50 (2.6%) |
| Severe undernutrition | 6 | 5.2 | 3 | 0.2 | 9 (0.4%) |
| Nutritional Risk Screening 2002 (NRS 2002) | |||||
| Without risk | 10 | 8.8 | 819 | 44.9 | 829 (42.8%) |
| Low risk | 3 | 2.6 | 137 | 7.5 | 140 (7.2%) |
| Moderate risk | 25 | 22.0 | 373 | 20.5 | 398 (20.5%) |
| High risk | 76 | 66.6 | 494 | 27.1 | 570 (29.4%) |
In the multivariate model, when adjusted for all the variables, there were significant differences in PI incidence according to age – every year of increase in age increased the patient's risk for PI in 1.05 (P < .001); length of hospital stay – every added day to the length hospital stay increased the patient's risk for PI in 1.04 (P < .001); having hypertension was associated with 1.62 higher risk for PI (P = .022); those receiving clinical treatment had 1.96 higher risk for PI compared with those receiving other types of treatment (P = .018); based on the NRS 2002 scores, those with moderate risk for undernutrition had 3.4 (P = .003) higher odds of developing PI, and those at a high risk for undernutrition had 4.4 (P < .001) higher risk for PI, compared with those without risk for undernutrition. Those classified as having severe undernutrition in the SGANS scale had 4.4 (P < .001) higher risk for PI compared with those classified in the other categories (Table 4).
TABLE 4.
Predictors of PI (final model)
| Variable | RR/OR a (95% CI) | RR/OR b (95% CI) |
|---|---|---|
| Age (years) | 1.05 (1.03‐1.06) | 1.05 (1.03‐1.06) |
| Sex (female) | 0.64 (0.44‐0.95) | 0.99 (0.65‐1.50) |
| Hypertension | 0.60 (0.41‐0.87) | 1.62 (1.07‐2.45) |
| Diabetes | 0.46 (0.31‐0.67) | 0.77 (0.50‐1.18) |
| Hospital type | ||
| Private | 1.00 | 1.00 |
| Public | 0.41 (0.28‐0.60) | 0.61 (0.39‐0.95) |
| Length of hospital stay (days) | 1.05 (1.04‐1.07) | 1.04 (1.03‐1.06) |
| Treatment type | ||
| Surgical | 1.00 | 1.00 |
| Clinical | 3.5 (2.12‐5.95) | 1.96 (1.12‐3.43) |
| BMI | ||
| Eutrophic | 1.00 | 1.00 |
| Underweight | 3.11 (1.95‐4.96) | 1.27 (0.76‐2.10) |
| Overweight | 0.92 (0.53‐1.60) | 1.11 (0.63‐1.96) |
| Obese | 0.95 (0.54‐1.66) | 1.22 (0.67‐2.21) |
| Nutritional Risk Screening 2002 (NRS 2002) | ||
| Without risk | 1.00 | 1.00 |
| Low risk | 1.77 (9.48‐6.45) | 2.21 (0.56‐8.62) |
| Moderate risk | 4.99 (2.39‐10.45) | 3.48 (1.51‐8.0) |
| High risk | 11.19 (5.79‐21.6) | 4.40 (2.03‐9.54) |
| Subjective Global Assessment Nutrition Scale (SGANS) | ||
| Low risk | 1.00 | 1.00 |
| Moderate malnutrition | 6.05 (3.51‐10.45) | 1.77 (0.95‐3.28) |
| Severe malnutrition | 13.46 (5.89‐30.73) | 4.40 (2.03‐9.54) |
| Braden Scale Nutrition Subscale (BSNS) | ||
| Excellent | 1.00 | 1.00 |
| Adequate | 0.90 (0.50‐1.61) | 1.07 (0.50‐2.31) |
| Probably inadequate | 0.57 (0.31‐1.03) | 1.01 (0.46‐2.20) |
| Completely inadequate | 0.22 (0.10‐0.47) | 0.91 (0.36‐2.29) |
Abbreviations: CI, confidence interval; OR, odds ratio; PI, pressure injury; RR, risk ratio.
Crude.
Adjusted for all variables.
4. DISCUSSION
Hospitalised patients are at a high risk for undernutrition, which if not detected and treated can compromise the quality of hospital care. Systematic screening of the patient nutritional status can help mitigate such risk and has been recommended in the literature. 19 Conducting nutritional screening as part of mainstream hospital care can help support timely implementation of nutritional therapy.20, 31 The importance of implementing nutritional therapy within the hospital settings is recognised by the Brazilian Ministry of Health. In Brazil, it is therefore mandatory the implementation of assessment protocols to all hospitalised patients within the public National Health System (SUS) as a mean to receive allocated budgets for the financing of enteral and parenteral nutritional therapies. 32 The current study investigated risk for undernutrition in hospitalised patients using three measurement tools – the BSNS, the SGANS, and the NRS 2002 – and showing that 36.7%, 2.5%, and 53% were at risk for undernutrition according to each of the three scales, respectively.
Several other studies have measured the prevalence of undernutrition in hospitalised patients using several measurement tools.12, 13, 33, 34, 35 In one study in which NRS 2002 was also used to assess the relationship between risk for undernutrition and PI incidence showed that the first nutritional assessment was a predictor of PI incidence. 35 A previous Brazilian study entitled IBRANUTRI, in which the SGANS scale was employed, showed that the prevalence of undernutrition was 48.1%, of which 12.5% had severe undernutrition.12, 13 Such rates are divergent from our findings, in which prevalence of patients with undernutrition (2.5%) or severe undernutrition (0.4%) were much lower. Another Brazilian study in which patient nutritional status was assessed the SGANS, the authors also found much higher rates than of the ones of our study (47.4% were low risk, 30.2% had moderate undernutrition, and 22.4% had severe undernutrition). 33 Despite such differences, the outcomes we obtained with the NRS 2002 and the BSNS were also high, similar to the outcomes of the SGANS scale. Another study with older adults has also showed a high prevalence of individuals who had severe undernutrition (22%) or moderate undernutrition (36%). 34
The risk factors for PI identified in our study are similar to the ones identified in the study conducted by Brito et al 32 which were age, type of hospital, length of hospital stay, risk for undernutrition, and nutritional status. With regards to age, our sample had 48% (n = 1937) of people aged 60 and over. Patients who were at risk for undernutrition had mean ages of between 62.5 and 77.9. However, if we considered only the group who had both high risk for under nutrition and did develop PI, the mean age varied depending on the measurement tool used to assess nutrition: 78.6 (SD = 15.5) in the NRS 2002; 80.6 (SD = 9.2) in the SGANS; and 81.8 (SD = 11.0) in the BSNS.
In the studies by Brito et al 33 and Coleman et al, 36 nutritional state and the age were important factors contributing to a higher risk for PI. However, in another study conducted in Brazil, 37 age did not predict PI incidence. This difference may be explained by the predominance of people aged 18 to 60 in this study sample (62.22%). 37 Increase in age is nevertheless considered to be one of the strongest risk factors for PI in several other studies when it is associated with other risk factors, such as undernutrition, immobility, and humidity.10, 34, 36, 38, 39
Hypertension has also been linked to higher PI incidence. In our study, this risk was 1.68 compared with those without hypertension. Other studies are needed to confirm this finding. We also showed that length of hospital stay in patients who were in risk for undernutrition was often high regardless of the scale used to assess this risk, varying from 6.2 (SD = 7.4) in the BSNS to 11.4 (SD = 8.6) in the SGANS scale. In those who had a risk for undernutrition and who developed PI, the length of hospital stay was significantly high, varying from 11.4 (SD = 9.1) days to 12.9 (SD = 12.6) days. In the IBRANUTRI study, 12 the mean time of hospital stay was of 9 days in patients who had moderate undernutrition, and 13 days in those who had severe undernutrition. High length of hospital stay has also been linked to high PI incidence in other studies.5, 7, 39
Although we found a significant link between the type of clinical treatment and the incidence of PI, other studies have not identified such link, and therefore further research is needed to establish this.1, 21 In our study, we found a significant link between patients classified as having severe undernutrition in the SGANS scale and the development of PI (2.93 higher chance compared with those with no risk for undernutrition); within the NRS 2002, those who were classified as having moderate or severe undernutrition presented 2.91 and 3.88 higher risk for PI, respectively. Other studies have also indicated a significant and positive relationship between any risk for undernutrition and PI incidence.13, 14, 15, 40 Given such consistent finding in the literature, it is essential that hospital institutions have nutritional screening strategies in place to identify or assess the risk for hospital‐related undernutrition so that preventative and therapeutic measures can be implemented to assist in nutritional treatment, prevent the installation of undernutrition and mitigate the risk of developing PI.
5. CONCLUSION
The nutritional risk assessment scales used in this study indicated a prevalence rate of patients at risk for undernutrition from 3.1% to 57.2%. We found a significant link between the presence of nutritional risk and the development of PI, with risk ratios varying from 2.91 to 3.88 higher in people who were at nutritional risk, compared with those who were not at risk for undernutrition.
ACKNOWLEDGEMENTS
We would like to thank blinded for peer review for their support with providing the team with the relevant literature. This study received financial support from blinded for peer review.
Serpa LF, Oliveira AS, Nogueira PC, de Gouveia Santos VLC. Risk for undernutrition and development of pressure injury in hospitalised patients in Brazil: Multicentre prospective cohort study. Int Wound J. 2020;17:916–924. 10.1111/iwj.13352
Funding information Nestlé Health Sciences, Grant/Award Number: 0000
REFERENCES
- 1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance . Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Perth, Australia: Cambridge Media; 2014. [Google Scholar]
- 2. National Pressure Ulcer Advisory Panel . Terms and definitions related to support surfaces. http://www.npuap.org. Accessed July 11, 2016.
- 3.Brazilian Association of Stomatherapy. Classification of Pressure Injuries—Consensus NPUAP 2016. —Culturally adapted for use in Brazil. http://sobest.org.br/textod/35. Accessed July 11, 2016.
- 4. Costa IG. Incidence of pressure ulcer in regional hospitals of Mato Grosso. Brazil Rev Gaúcha Enferm. 2010;31(4):693‐700. [DOI] [PubMed] [Google Scholar]
- 5. Campanili TCGF, Santos VLC d G, Strazzieri‐Pulido KC, Thomaz P d BM, Nogueira PC. Incidence of pressure ulcers in cardiopulmonary intensive care unit patients. Rev da Esc Enferm da USP. 2015;49:7‐14. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342015000700007&lng=pt&nrm=iso&tlng=en. [DOI] [PubMed] [Google Scholar]
- 6. Serpa LF, Santos VLCG, Campanili TCGF, Queiroz M. Predictive validity of the Braden scale for pressure ulcer risk in critical care patients. Re Latino‐Am Enfermagem. 2011;19(1):1‐8. http://www.scielo.br/pdf/rlae/v19n1/pt_08.pdf. Accessed May 24, 2016. [DOI] [PubMed] [Google Scholar]
- 7. Rogenski NMB, Kurcgant P. The incidence of pressure ulcers after the implementation of a prevention protocol. Rev Latino‐Am Enfermagem. 2012;20(2):1‐7. http://www.scielo.br/pdf/rlae/v20n2/pt_16. Accessed March 23, 2017. [DOI] [PubMed] [Google Scholar]
- 8. Borghardt AT, Prado TN, Araújo TM, Rogenski NMB, Bringuente MOE. Avaliação das escalas de risco para úlcera por pressão em pacientes críticos: uma coorte prospectiva. Rev Latino‐Am Enfermagem. 2015;23(1):28‐35. [Google Scholar]
- 9. Anselmi ML, Peduzzi M, França Junior I. Incidence of pressure ulcer and nursing interventions. Acta Paul Enferm. 2009;22(3):257‐264. http://www.scielo.br/pdf/ape/v22n3/en_a04v22n3.pdf. [Google Scholar]
- 10. Diccini S, Cadamuro C, LIS I. The incidence of pressure ulcer in neurosurgical patients from a university hospital. Acta Paul Enferm. 2009;22(2):205‐209. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-21002009000200014. [Google Scholar]
- 11. Souza DMST, Santos VLCG. Pressure ulcers in the elderly: analysis of prevalence and risk factors. Rev Estima. 2006;4(1):45. [Google Scholar]
- 12. Correia MITD, Campos ACL. Prevalence of hospital malnutrition in Latin America: the multicenter ELAN study. Nutrition. 2003;19(10):823‐825. [DOI] [PubMed] [Google Scholar]
- 13. Waitzberg DL, Caiaffa WT, Correia MITD. Hospital malnutrition: the Brazilian national survey (Ibranutri): a study of 4,000 patients. Nutrition. 2001;17(7–8):573‐580. [DOI] [PubMed] [Google Scholar]
- 14. Bavelaar JW, Otter CD, Bodegraven AA, Thijs A, Bokhorst‐Schueren MA. Diagnosis and treatment of (disease‐related) in‐hospital malnutrition: the performance of medical and nursing staff. Clin Nutr. 2008;27(3):431‐438. [DOI] [PubMed] [Google Scholar]
- 15. Braunschweig C, Gomez S, Sheean PM. Impact of declines in nutritional status on outcomes in adult patients hospitalized for more than 7 days. J Am Diet Assoc. 2000;100(11):1316‐1322. [DOI] [PubMed] [Google Scholar]
- 16. Shahin ESM, Meijers JMM, Schols JMGA, Tannen A, Halfens RJG, Dassen T. The relationship between malnutrition parameters and pressure ulcers in hospitals and nursing homes. Nutrition. 2010;26:886‐889. [DOI] [PubMed] [Google Scholar]
- 17. Langer G, Schloemer G, Knerr A, et al. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2003;4:CD003216. [DOI] [PubMed] [Google Scholar]
- 18. Stratton RJ, Ek AC, Engfer M, et al. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta‐analysis. Ageing Res Rev. 2005;4(3):422‐450. [DOI] [PubMed] [Google Scholar]
- 19. American Dietetic Association . Definition for nutrition screening and assessment. J Am Diet Assoc. 1994;94(8):838‐839. [DOI] [PubMed] [Google Scholar]
- 20.Brazilian Society of Parenteral and Enteral Nutrition, Brazilian Association of Nutrology: Screening and Assessment of Nutritional Status. Projeto diretrizes, 2008. https://www.yumpu.com/pt/document/view/43875054/triagem‐e‐avaliacao‐do‐estado‐nutricional‐projeto‐diretrizes. Accessed November 18, 2019.
- 21. White JV, Guenter P, Jensen G, et al. ASPEN malnutrition task force. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Parenter Enteral Nutr. 2012;36:275‐283. [DOI] [PubMed] [Google Scholar]
- 22. Raslan M, Gonzales MC, Dias MCG, et al. Aplicabilidade dos métodos de triagem nutricional no paciente hospitalizado. Rev Nutr. 2008;21(5):553‐561. [Google Scholar]
- 23. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden scale for predicting pressure sore risk. Nurs Res. 1987;36(4):205‐210. [PubMed] [Google Scholar]
- 24. Paranhos WY, Santos VLCG. Avaliação de risco para úlceras de pressão por meio da Escala de Braden, na lingua Portuguesa. Rev Esc Enf USP. 1999;33(special issue):191‐206. [Google Scholar]
- 25. Ayello EA, Braden B. How and why to do pressure ulcer risk assessment. Adv Skin Wound Care. 2002;15:125‐133. [DOI] [PubMed] [Google Scholar]
- 26. Kennerly S, Boss L, Yap TL, et al. Utility of Braden scale nutrition subscale ratings as an indicator of dietary intake and weight outcomes among nursing home residents at risk for pressure ulcers. Healthcare. 2015;3:879‐897. https://www.ncbi.nlm.nih.gov/pubmed/27417802. Accessed July 17, 2017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. Fernandes LM, Caliri MHL. Using the Braden and Glasgow scales to predict pressure ulcer risk in patients hospitalized at intensive care units. Rev Latino‐Am Enfermagem. 2008;16(6):973‐978. [DOI] [PubMed] [Google Scholar]
- 28. Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr. 1987;11:8‐13. [DOI] [PubMed] [Google Scholar]
- 29. Kondrup J, Rasmussen HH, Hamberg O. Nutrition risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr. 2003;22(3):321‐336. [DOI] [PubMed] [Google Scholar]
- 30. Aquino RC, Philippi ST. Desenvolvimento e avaliação de instrumentos de triagem nutricional. Rev Bras Enferm, Brasília. 2012;65(4):607‐613. [DOI] [PubMed] [Google Scholar]
- 31. Ferguson M, Capra S, Bauer J, et al. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition. 1999;15(6):458‐464. [DOI] [PubMed] [Google Scholar]
- 32.Secretaria de Assistência à Saúde. Portaria n°. 131, de 8 de Março de. 2005. https://www.normasbrasil.com.br/norma/portaria-131-2005_191046.html. Accessed January 9, 2020.
- 33. Brito PA, Generoso SV, Correia MITD. Prevalence of pressure ulcers in hospitals in Brazil and association with nutritional status—a multicenter, cross‐sectional study. Nutrition. 2013;29:646‐649. [DOI] [PubMed] [Google Scholar]
- 34. Gaino NM, Leandro‐Merchi VA, Oliveira MRM. Idosos hospitalizados: estado nutricional, dieta, doença e tempo de internação. Rev Bras Nutr Clin. 2007;22(4):273‐279. [Google Scholar]
- 35. Alhaug J, Gay CL, Henriksen C, Lerdal A. Pressure ulcer is associated with malnutrition as assessed by Nutritional Risk Screening (NRS 2002) in a mixed hospital population. Food Nutr Res. 2017;61:1 https://www.tandfonline.com/doi/full/10.1080/16546628.2017.1324230. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36. Coleman C, Gorecki C, Nelson E, et al. Patient risk factors for pressure ulcer development: systematic review. Int J Nurs Stud. 2013;50(7):974‐1003. [DOI] [PubMed] [Google Scholar]
- 37. Matozinhos FP, Velasquez‐Melendez G, Tiensoli SD, Moreira AD, Gomes FSL. Factors associated with the incidence of pressure ulcer during hospital stay. Rev Esc Enferm USP. 2017;51:e03223 10.1590/S1980-220X2016015803223. [DOI] [PubMed] [Google Scholar]
- 38. Sakashita VM, Nascimento ML. Major risk factors for the development of pressure ulcer in the elderly and the importance of nutrition in the treatment handling. Geriatria Gerontologia. 2011;5(4):253‐260. [Google Scholar]
- 39. Teixeira AKS, Nascimento TS, Sousa ITL, Sampaio LRL, ARM P. Incidence of pressure injuries in intensive care unit in an accredited hospital. Estima. 2017;15(3):152‐160. https://www.revistaestima.com.br/index.php/estima/article/view/545/pdf. [Google Scholar]
- 40. Neloska L, Damevska K, Nikolchev A, Pavleska L, Petreska‐Zovic B, Kostov M. The association between malnutrition and pressure ulcers in elderly in long‐term care facility. Open Access Maced J Med Sci. 2016;4(3):423‐427. [DOI] [PMC free article] [PubMed] [Google Scholar]