Lesión por presión categoría iv secundaria a valoración inadecuada de enfermería

Abstract

Introduction: Pressure injuries are wounds that occur on the skin causing deterioration of its integrity; According to the WHO, these injuries affect 9 out of 100 people hospitalized, regardless of age or pathology, their prevalence is 5 to 12% worldwide and 7% in Latin America. Objective: Assess the risk of the presence of recurrent pressure injuries using the Norton and Braden scales for proper nursing management. Methodology: The present case analysis is based on an elderly female patient with moderate dependence, a history of arterial hypertension and osteoarthritis 20 years ago, who was hospitalized for several days with a diagnosis of acute bronchitis and due to an inadequate assessment of nursing He presented pressure injuries at the heel and sacral region. Descriptive-explanatory research was used and as an observation and unstructured interview technique. Results: A comprehensive geriatric assessment was performed, for which the Barthel scale was applied, a score of 65/100 was obtained, classified as a moderate dependence; This scale was used due to its usefulness in research carried out to assess the level of dependency in older adults: Mexico with 116 older adults and Peru with 183 older adults. To assess the risk of presenting pressure injuries, the Norton scale was applied, a score of 17/20 was obtained; In addition, the Braden scale was used, a score of 18/23 was obtained, since it evaluates other important items such as nutrition and friction, those that are not valued in Norton; It should be noted that according to studies, Braden has a higher level of quality, predictability and reliability compared to Norton; when applying these scales, it was demonstrated that the patient had moderate dependence and a slight risk of developing pressure injuries, it was confirmed that the cause of the lesions she presented was the result of the inadequate assessment of nursing; As one of the main interventions in primary health care, from the nursing approach based on the theories of Dorothea Orem and Nola Pender, family members were educated about the care they should offer. The pressure lesions evolved favorably and the complete regeneration of the tissues was obtained.