Skin injuries in hospitalized elderly

1Universidade Estadual de Ponta Grossa – Departamento de Enfermagem e Saúde Pública – Ponta Grossa/PR – Brazil. 2Mölnlycke Health Care Brasil – Almirante Tamandaré/PR – Brazil. Correspondence author: Clóris Regina Blanski Grden | Rua Teodoro Sampaio, 888 | ZIP Code: 84.036-070 – Ponta Grossa/PR, Brazil | E-mail: reginablanski@hotmail.com Received: Sept 01 2018 | Accepted: Dec 12 2018 ABSTRACT Objective: To identify the prevalence of skin injuries in hospitalized elderly. Method: Cross-sectional study with 202 elderly patients selected for convenience and hospitalized in a hospital in Parana (Brazil). Data were collected between September 2017 and January 2018. The Mini-mental State Examination and the physical examination of nursing in the elderly were used. Data were submitted to the exploratory analysis and described by absolute frequency, percentage, means and standard deviations. Results: Women predominance (51%), age range between 60-69 years (42.5%), married (52%) and low educational level (59.4%). It was identifi ed that 128 (63.4%) elderly had clean scalp; 116(57.4%), skin with normal coloring; 104 (51.5%), normal turgor; 138 (68.3%), normal temperature; 160 (79.2%) of fi ne thickness; 101 (50%), soft texture; 144 (71.3%) with scar; 182 (90.1%), sensitivity; and 152 (75.3%), pruritus. Prevalence of eutrophic body mass index (38.6%) and 176 (87.1%) elderly had skin injuries; 152 (75.3%) had primary injuries and 151 (74.7%), secondary injuries. Conclusion: T he study identifi ed the high index of skin injuries in hospitalized elderly. The results are expected to make nurses aware of the importance of the physical examination of the skin as a fundamental step in planning preventive, monitoring and care actions.


INTRODUCTION
The changes that constitute and influence the aging process are complex and although this phenomenon is a growing world reality, the health services present numerous challenges to meet the health care needs of this population segment.
Psychological, functional and social changes interfere in the aging process, favoring the gradual loss of physiological reserves, the greater risk of contracting diseases and the general decline in the individual's intrinsic capacity 1 .Among the innumerable physiological changes that occur, it can highlight changes in the integumentary system, such as: reduction of dermal thickness, loss of elastic fibers, reduction of subcutaneous adipose tissue and reduction of capillaries in the skin 2 , among others, which may contribute to that the elderly become more susceptible to skin injuries.
Inadequate nutrition, invasive devices, mechanical strength, excess moisture, diaper use, and physical immobility are risk factors that predispose the appearance of the injuries 3,4 , which are characterized as one of the main complications that can affect hospitalized patients 5,6 , especially the elderly.
In general, this age segment tends to present several pathologies, a condition that contributes to hospitalization, with longer hospital stay and consequent increase in health costs 7 .In this context, the importance of the nurse performing the physical examination of the skin in the elderly with the direction of the early detection of injuries, traumas and other pathologies is emphasized, which can accentuate functional limitations, with repercussion for autonomy, independence and quality of life.

Skin injuries in hospitalized elderly
It is understood that in the hospitalized elderly, the development of integumentary injuries is a negative indicator of the quality of care 8 , which is responsible for maintaining skin integrity.

OBJECTIVE
In view of the above, the objective of this study was to identify the prevalence of skin injuries in the elderly hospitalized in a teaching hospital through physical examination by the nurse.visual constructive capacity 10 .The score ranges from zero to 30, with the following cutoffs for evaluation: 13 points for illiterates; 18 points, low and average schooling; and 26 points, high schooling 9 .

METHODS
In order to classify and characterize the sample, a sociodemographic and clinical questionnaire constructed specifically for the study was prepared.The elderly was submitted to the physical examination of nursing, which included: assessment of skin and attachments of the various segments, scalp and hair, face skin, turgor, skin temperature, thickness, texture, scar presence, skin sensitivity, pruritus, nails, nutrition measures (body mass index [BMI]) and primary and secondary elementary injuries.The instrument was constructed based on references that address the semiology of the skin, with adaptation to the elderly patient [11][12][13] .
The data collection was realized by nurses residing in the elderly health and nursing students, scholars of scientific initiation, who were trained by a nurse specialist in stomatherapy, with clinical experience in the area, through a 45 hours theoretical-practical update on evaluation of skin in the elderly, which included the following themes: elemental injuries, pressure injuries, friction injuries, adhesive injuries, incontinence associated dermatitis, prevention and treatment for pressure injuries.
The data were tabulated and analyzed using Stata software®, version 12.These were submitted to the exploratory analysis and described by means of absolute frequency and percentage, means and their standard deviations.
The project was approved by the Ethics Committee of the State University of Ponta Grossa with an opinion nº.1.461.471and by CAAE nº 66782217.9.0000.5689.
The ethical precepts of voluntary and consensual participation of each subject were respected, according to the current resolution at the time of the research.

DISCUSSION
Among the participants, there was a predominance of women, in line with the results of national surveys on injuries among hospitalized elderly 5,14 and in the community 4 .Hormonal alterations from the aging process may contribute to the appearance of skin injuries in the elderly 8 .
For the age variable, both the mean age and the age group identified are like the descriptive and exploratory research performed with 55 hospitalized elderly in Paraiba, in which a higher prevalence of injuries was observed in the elderly 8 ; this may be justified by the late search for health services or the lack of follow-up service to the elderly.
The analysis of marital status pointed out a higher proportion of married elderly, as expected for the age group of the study population and identified in an exploratory research on the evaluation of skin in hospitalized elderly, in which 50% of the participants were married 14 .It is understood the married condition as a positive aspect for the elderly regarding the assistance in life activities and instrumental of daily life, collaborating for actions of prevention and care of the skin.
The expressive percentage of elderly with low educational level identified in this study is similar to the results of the cross-sectional, retrospective study and through data recorded in 1.168 medical records of the Medical Archive Service of the Hospital of Clinics of the Federal University of Triangulo Mineiro 5 , in which participants predominated with low level of education.
One possible explanation can be attributed to the profile of the community served by the hospital, linked to the Unified Health System, in which elderly people with unfavorable economic conditions predominate, most of whom did not have access to the education system.
As for white skin color, it becomes more susceptible to integumentar y injuries due to its histological characteristics, such as less melanin protection and fewer collagen fibers 15,16 .In agreement with the findings, the transversal research realized in Palmas with 259 elderly people stands out, of which 66.7% had white skin color 16 .
For the variables period and average time of hospitalization, the findings differ from other national studies, which identified a longer average time of hospitalization (12.7 and 10 days) 13,14 , which can be attributed to the fact that the interviewees were hospitalized in sectors considered of high hospital turnover. of the 2143 elderly people they had chronic diseases 4 .

Most
Although the majority of the interviewees reported not being a smoker or an alcoholic, these habits are considered public health problems, due to the high mortality of the diseases from these conditions 17 .On the skin, such substances can cause tissue breakage, injuring cells, resulting in premature aging and interfering with skin integrity 17 .
Among the participants, it was verified the predominance of oral diet.Nutrition is one of the intrinsic factors that affects the skin and its functionality 18 .
Authors indicate the association between nutrition and the delay of healing with the development of injuries 19 .
The high use of medication identified in the elderly in this study 18 is in line with the prospective cohort study conducted in a teaching hospital with 215 elderly people, which revealed that 69.7% used medication 20 .Drugs can cause changes that may decrease skin sensitivity and cause allergies.

Skin injuries in hospitalized elderly
The use of medical and mobility devices can contribute to the occurrence of traumas and restrictions.
During hospitalization, the elderly may be subject to the use of devices necessary for their treatment, such as catheters, tubes, drains, probes and others.However, medical devices that have a skin adherence action favor rupture of cutaneous integrity from their manipulation and removal, while those of mobility have an impact on daily care and position exchange 3 .
The high scores obtained in cognitive screening (MMSE) by the elderly participants can be attributed to the age characteristic of the sample, composed predominantly of young and active elderly.However, no research has been found on cognitive screening in the elderly with skin injuries for comparison with the ndings.
In the accomplishment of the integumentary physical examination, it was observed the scarcity of studies about the subject, specifically in the elderly age segment.
However, the relevance of the identification and early screening of skin injuries through the integumentary physical examination by the nursing team is understood.
In the hospital context, the elderly presented a high number of cutaneous injuries, especially those called elementary, defined as any structural modification of the skin and that have different causes, such as circulatory, hyperplastic, metabolic, inflammatory and degenerative 21 .
Among the elemental injuries, the predominance of color changes, which affect the epidermis and the dermis, have no relief or consistency and occur by vasodilatation, constriction or extravasation of red blood cells and by decrease or increase of melanin or deposits of others pigments and substances 11 .Likewise, there has been a high amount of texture changes and tissue thickness and loss which may arise from pathological elimination or destruction and repair in subcutaneous tissues 11 .
Cross-sectional design was a limiting factor in the evaluation between cause and effect relationships.In addition, sampling is representative of a local community, so it does not allow generalization of results to other territories.It is suggested that investigations realized with this age group may include the home visit to collect information, as well as possible evaluations of the professionals' knowledge about the subject and their actions.
It is pointed out that the scarcity of epidemiological studies on skin injuries in the elderly age segment made it difficult to compare the findings of the present investigation, which justifies the necessity for epidemiological studies especially with this population.

CONCLUSION
The study identified the high prevalence of skin injuries in the elderly hospitalized in a teaching hospital through physical examination by the nurse.
The integumentary injuries may interfere with the functional status and contribute to an increase in length of hospital stay and premature mortality.
In this context, it is considered important that the professional nurse perform the physical examination of the skin with a careful evaluation to identify the changes, whether natural or pathological, that the elderly can present, thus enabling the construction of gerontological care plans the specific needs of this age group.
This is a cross-sectional study, realized with a convenience sample of 202 elderly people hospitalized in a medical clinic, in a medium-sized hospital in a municipality in the state of Parana (Brazil), from September 2017 to January 2018.The criteria used for the selection of the sample were: a. Age above or equal to 60 years; b.Be hospitalized for at least 24 hours in the institution during the period of data collection; c.Have cognitive ability to participate in the study 9 .In the case of the elderly without cognitive conditions to answer the research questions, at the interview stage the caregiver/family member was invited to participate; for this the following inclusion criterion were listed: a. Being 18 years or more; b.Being a caregiver/family member; c.Have lived with the elderly for at least three months.Initially, the data collection performed at the hospitalization unit contemplated the cognitive screening through the Mini-mental State Examination (MMSE).The instrument has 11 items grouped into seven categories, represented by groups of specific cognitive functions: temporal orientation, spatial orientation, immediate memory, attention and calculation, evocation memory, language and of the elderly reported chronic diseases, a condition expected by the characteristic of the sample being with hospitalized elderly.Authors point out that the presence of injuries is more prevalent among the elderly with at least one chronic disease, especially diabetes, cardiovascular diseases and immunosupressors, which may alter the healing process 4 .e ndings are similar to the descriptive and exploratory research that is part of the Health, Well-being and Aging Study (HWBA), developed to outline the living and health conditions of elderly people living in the city of Sao Paulo, where 54.7%

Table 1 .
Grden CRB, Ivastcheschen T, Cabral LPA, Reche PM, Oliveira DAS, Bordin D Distribution of the sociodemographic and clinical characteristics of the elderly hospitalized in a teaching hospital.Paraná, Brazil, 2018.

Table 2 .
Distribution of the characteristics of the integumentary physical examination of the elderly hospitalized in a teaching hospital.Paraná, Brazil, 2018.