Incidence of injuries confused with pressure injuries in oncology intensive care unit

1.Universidade Federal de Minas Gerais – Escola de Enfermagem – Departamento de Enfermagem Básica – Belo Horizonte/MG – Brazil. 2.Instituto Mário Penna – Hospital Luxemburgo – Belo Horizonte/MG – Brazil. Corresponding author: piresjuniorr@hotmail.com Received: Nov. 21, 2018 | Accepted: Feb. 25, 2019 ABSTRACT Objectives: Estimate the incidence of the confounding lesions (CL) with pressure injuries in an intensive care unit of an oncology hospital, to characterize the patients and the confused injuries. Methods: Prospective cohort study conducted in an adult intensive care unit of an oncology hospital in Belo Horizonte, Minas Gerais. The sample consisted of 67 patients who met the inclusion criteria. The data were collected during the period of one month by single researcher stomatherapist and registered in the form prepared for this purpose. The study was approved by the Research Ethics Committee. Results: 58.1% were women, 65.1% were elderly, 51.2% were white, with gastrointestinal cancer predominating, 71.6% were using adjuvant chemotherapy, with below-normal body mass index, 100% had urinary incontinence or fecal and diaper use. The incidence of these injuries was 35.8%, and the average time for their onset was 11 days after admission. Most patients had skin changes such as maceration, peeling, erythema, dehydration, and edema. Conclusion: We can conclude that the incidence of confused injuries is high in oncology patients admitted to intensive care units. It was possible to describe the demographic and clinical profile of the patients of the sample and to characterize the injuries and the skin around them.


INTRODUCTION
Since the beginning of the 21st century, skin lesions, called cutaneous lesions or simply wounds, have received special attention from health professionals due to their high prevalence and incidence. In addition, they cause a socioeconomic impact for patients, families, health services and society in general and are responsible for negatively affecting the health and quality of life of people affected 1 .
In the group of lesions that affect the hospitalized patients, we highlight the pressure injury (PI), called pressure ulcer until April 2016, when the nomenclature was changed by the National Pressure Ulcer Advisory Panel (NPUAP) 2,3 . On that same date, the concept was revised and PI was considered to be localized damage to the skin and/or underlying soft tissue, usually on bone prominence, or may still be related to medical equipment or other devices. The lesion may present as intact skin or as an open ulcer and can be painful. Occurs as a result of exposure to pressure or shear pressure. Tolerance of soft tissue to pressure and shear can also be affected by microclimate, nutrition, perfusion, associated diseases, and tissue condition 2,3 . e multiplicity of risk factors related to the development of PI is, concurrently, with other types of skin lesions. is situation often leads professionals to confuse the presence of PI with cutaneous lesions of other causes. Stage 2 PI is de ned as partial skin loss with dermal exposure. Because it appears to be moist, pink or red in color, or as an intact or ruptured blister, this stage is mistaken for incontinenceassociated dermatitis (IAD), friction lesion (FL), and injury related to medical adhesives 3 . In the present study, these lesions will be called confounding lesions (CLs) for the occurrence of PI. Some professionals tend to classify skin lesions as PI. is fact results in the lack of institutional records of CLs.
Incidence of injuries confused with pressure injuries in oncology intensive care unit to the patient; in addition, its occurrence is of monthly compulsory noti cation.
Since 2009, the guidelines published by NPUAP and the European Pressure Ulcer Advisory Panel (EPUAP) recognize the IAD as a distinct condition of PI and recommend that care professionals be trained to carry out the di erential IAD is a type of dermatitis associated with moisture de ned as the prolonged exposure of the skin to the e uent (urine, feces, exudate, and sweat) with erythema and surface edema, and may be accompanied by erosion, accid with serous exudate or secondary infection. It mainly a ects the perineal, perianal and inguinal regions 5 .
Another type of CL is FL, considered a traumatic injury that occurs more frequently in the upper and lower extremities of the elderly, resulting from friction or the combination of friction and shear. This damage causes separation of the epidermis from the dermis and results in a partial thickness wound or causes total separation of the epidermis and dermis from the underlying structures, resulting in a full thickness wound 6 . e third lesion in the CL group is the lesion related to medical adhesives, the de nition of which is the occurrence of hyperemia and/or other manifestation of skin alterations, such as gallbladder, icten, erosion and rupture, persisting for more than 30 minutes after removal of the medical adhesive.
In general, these lesions are related to mechanical and chemical trauma from the use of these medical adhesives 7 .
Although it is an old problem, it is inferred that the occurrence of CLs has increased with increasing longevity of the Brazilian population and the incidence of chronicdegenerative diseases, especially cancer. is context raises speci c studies related to these lesions, common in clinical practice, but little studied. e results can contribute to the systematization of CL nomenclature and encourage discussion about prevention and treatment. The data were collected by a single stomatologist researcher during the period of one month. In order to ll out the data collection instrument, information extracted from the electronic medical record was used and daily inspection of the patients' skin at the moment of bed hygiene, in order to avoid further discomfort to patients.
In order to meet the proposed objectives, the following study variables were chosen: CL (IAD, Regarding the use of medications, 11.9% did not use.    Table 4. It was noticed that some patients used more than one product for prevention of IAD. Cleansing the skin for diaper replacement was performed with mild soap and water. For skin protection, most used essential fatty acids (57/85%).
Patients who developed IAD were using skin protection products: 14 (100%) essential fatty acids and 9 (64.3%) zinc oxide. According to practitioners, it is common to carry out the mixing of the two products for application in the diaper region.
Considering the 24 participants who presented CL, one maintained intact skin around the lesion. e remaining 23 (87.5%) presented some type of alteration, such as maceration

DISCUSSION
It is noteworthy that in the databases there are no publications regarding the incidence and prevalence of CLs -IAD, FL, and injury related to medical adhesiveconsidered together. In this study, the estimated incidence of these lesions was 35.8%, with an average of 11.0 (± 13.9) days and a median of 5.0 days for its appearance. These data are surprising, therefore, these lesions can no longer be ignored by clinical practice professionals and managers of hospital institutions.
A prospective cohort study by Konya et al. 8  In a study conducted in Japan, prevalence ranged from 3 to 9% among a total of 410 people aged 73-87 years 12 . In Brazil, a study with cancer patients obtained a prevalence of FL of 3.3% and the majority were female elderly 13   e results of this study corroborate another whose results con rmed that 87% of white female patients developed IAD 16 .
Black skin appears to be a protective factor of skin lesions, because of its thickness, which makes it more resistant 10 .
In the long-stay institution scenario, the incidence of ICD was 8% lower than that obtained in this study 20 .
Most of the study patients were on urinary incontinence devices, such as a bladder catheter and a disposable diaper.
ese data were also present in the Brazilian study with adult patients to evaluate the main technologies applied by the nursing team in urinary control, which identi ed that 60% of the patients used diapers, followed by drainage by intermittent catheterization (24.8%), 21 .
The skin of the perineal region of all patients was sanitized during diaper changes with water plus neutral soap.
e continuous use of neutral soaps and other substances for hygiene causes changes in the barrier structure of the skin, which leads to dryness, in addition to increasing the pH of the skin, which is slightly acidic 5 .
e friction of the skin to remove irritating residues, such as ointments, oily creams, and oils, also causes disturbances in the barrier function of the skin through mechanical action 5 . at is, in addition to the aggression of the skin of the sample patients with urine and feces contact, there was also aggression by the product used for hygiene and friction to remove essential fatty acids and zinc oxide ointment.
In the study, it was identified that the majority of participants used a disposable diaper, which was changed four times a day, even in patients with more episodes of liquid feces per day. is action is related to the contract with supplementary health, however, when the diaper region is kept exposed to contact with the urinary and intestinal eliminations, it increases the risk of the patient developing ICD.
e international consensus on ICD classi es as skin protectors only vaseline-based ointment (not available in Brazil), dimethicone and liquid acrylate 4 . However, many study participants used the essential fatty acids to prevent dermatitis, although this product is classi ed as an emollient and should only be used to prevent loss of moisture by the skin 5 .
More: essential fatty acids are absorbed by the disposable diaper as well as any liquid substance, reducing the ability to absorb e uents and keeping the skin exposed to moisture for a longer period. In the present study, essential fatty acids were used indiscriminately, even mixed with other products, which may have contributed to the maintenance of skin exposed to moisture for a longer period.
e study had limitations related mainly to its casuistry, in addition to being performed in only one hospital specialized in oncology, with a collection time of only one month, which