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ORIGINAL ARTICLE12-13-2024
Nurses’ experience regarding patient safety in mobile pre-hospital care
- Eduardo Dias Filipe
, - Roberto Chrispim Modesto ,
- Hercules de Oliveira Carmo ,
- Haviley Oliveira Martins ,
- Maristela Santini Martins
Abstract
ORIGINAL ARTICLENurses’ experience regarding patient safety in mobile pre-hospital care
Revista Brasileira de Enfermagem. 2024;77(5):e20230529
DOI 10.1590/0034-7167-2023-0529
- Eduardo Dias Filipe ,
- Roberto Chrispim Modesto ,
- Hercules de Oliveira Carmo ,
- Haviley Oliveira Martins ,
- Maristela Santini Martins
Views0See moreABSTRACT
Objectives:
to understand nurses’ experience regarding patient safety in mobile pre-hospital care.
Method:
a qualitative, exploratory and descriptive study, conducted with nurses active in mobile pre-hospital care services. Semi-structured interviews were conducted, audio-graved and submitted to Bardin’s content analysis.
Results:
from four thematic categories established, nurses reported the care and management skills necessary to work in this service. They demonstrated a commitment to ensuring safe care for patients, staff and spectators. They highlighted the actions taken to prevent and mitigate incidents. However, they based their experiences on practice protocols and individual actions, expressing the need to improve knowledge about patient safety.
Final Considerations:
mobile pre-hospital care nurses’ experience in relation to patient safety was limited, suggesting the need for training on the subject, alignment of work processes and implementation of strategies, aiming to guarantee safe care.
- Eduardo Dias Filipe
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ORIGINAL ARTICLE12-13-2024
Stress in nursing workers caring for people with COVID-19
Revista Brasileira de Enfermagem. 2024;77(5):e20230542
Abstract
ORIGINAL ARTICLEStress in nursing workers caring for people with COVID-19
Revista Brasileira de Enfermagem. 2024;77(5):e20230542
DOI 10.1590/0034-7167-2023-0542
Views1See moreABSTRACT
Objectives:
to analyze stress from the perspective of nursing workers caring for people with COVID-19 in a public hospital in the Recôncavo region of Bahia.
Methods:
this is an exploratory qualitative study, conducted through semi-structured interviews. The data were analyzed using word clouds, similarity trees, and content analysis.
Results:
nursing workers were exposed to stress while attending to patients with COVID-19. The reported stressors in the workplace included: work overload, lack of planning, speed in performing tasks, fatigue, lack of participation in decision-making, lack of support from management, technological changes, excessive responsibility without preparation, interpersonal conflicts, and professional undervaluation.
Conclusions:
exposure to these stressors leads to emotional exhaustion and demotivation, which were intensified during the COVID-19 pandemic.
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ORIGINAL ARTICLE12-13-2024
Knowledge and attitudes of nursing students regarding the sexuality of older adults: a quasi-experimental study
- Ana Carolina Macri Gaspar Vendramini ,
- Rosemeiry Capriata de Souza Azevedo ,
- Priscila Aguiar Mendes ,
- Janderson Diego Pimenta da Silva ,
- Annelita Almeida Oliveira Reiners , [ … ],
- Amanda Cristina de Souza Andrade
Abstract
ORIGINAL ARTICLEKnowledge and attitudes of nursing students regarding the sexuality of older adults: a quasi-experimental study
Revista Brasileira de Enfermagem. 2024;77(5):e20240011
DOI 10.1590/0034-7167-2024-0011
- Ana Carolina Macri Gaspar Vendramini ,
- Rosemeiry Capriata de Souza Azevedo ,
- Priscila Aguiar Mendes ,
- Janderson Diego Pimenta da Silva ,
- Annelita Almeida Oliveira Reiners ,
- Amanda Cristina de Souza Andrade
Views0See moreABSTRACT
Objectives:
to compare the knowledge and attitudes of nursing students regarding sexual behavior and sexually transmitted infections (STIs) in older adults before and after an educational intervention.
Methods:
this quasi-experimental study involved a convenience sample of 45 nursing students from a public university, conducted in three stages: pre-intervention, intervention, and post-intervention. A questionnaire was used to assess sociodemographic characteristics, academic training, and knowledge and attitudes on the topic. The intervention was an educational web conference. Paired t-test and Wilcoxon test were used for data analysis.
Results:
there was a statistically significant difference in the knowledge and attitude scores of nursing students before and after the educational intervention (p < 0.001). A significant increase was observed in the knowledge score (from 9.3 to 12.2) and attitude score (from 108 to 117.2) in the post-intervention phase.
Conclusions:
the knowledge of nursing students regarding the sexuality of older adults increased after the educational intervention, and their attitudes on the subject became more positive.
- Ana Carolina Macri Gaspar Vendramini
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ORIGINAL ARTICLE12-13-2024
Educational booklet on labor and delivery: validity study
- Michelle Tatiane Carvalho Gonçalves ,
- Ana Roberta Vilarouca da Silva ,
- Mara Cristina Ribeiro Furlan ,
- Bruna Moretti Luchesi ,
- Tatiana Carvalho Reis Martins
Abstract
ORIGINAL ARTICLEEducational booklet on labor and delivery: validity study
Revista Brasileira de Enfermagem. 2024;77(5):e20240138
DOI 10.1590/0034-7167-2024-0138
- Michelle Tatiane Carvalho Gonçalves ,
- Ana Roberta Vilarouca da Silva ,
- Mara Cristina Ribeiro Furlan ,
- Bruna Moretti Luchesi ,
- Tatiana Carvalho Reis Martins
Views2See moreABSTRACT
Objectives:
to develop and validate an educational booklet on labor and delivery for pregnant women.
Methods:
this methodological study involved constructing and validating a booklet based on Echer’s framework. We used the Content Validity Index and Cronbach’s alpha for content and face validation, selecting judges according to Fering’s criteria. We then conducted a clinical validation with the target population.
Results:
the booklet, developed based on evidence from an integrative review and validated by judges and the target audience, achieved global Content Validity Index of 0.919 and 0.913, respectively. After clinical validation with 22 pregnant women, it included 28 topics and 48 pages, with illustrations by a graphic designer.
Conclusions:
expert judges and the target audience considered this educational technology valid, deeming it a relevant tool for promoting the health of pregnant women.
- Michelle Tatiane Carvalho Gonçalves
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12-08-2024
Contexto ibero-americano da enfermagem: construindo e compartilhando conhecimento
Revista Brasileira de Enfermagem. 2024;77(1):e770101
Abstract
Contexto ibero-americano da enfermagem: construindo e compartilhando conhecimento
Revista Brasileira de Enfermagem. 2024;77(1):e770101
DOI 10.1590/0034-7167.2024770101pt
Views0Na próxima semana, acontecerão dois grandes eventos científicos em Madri e Granada (Espanha). Serão atividades internacionais, específicas e de forma muito especial, embora não exclusivas do campo ibero-americano, organizadas e desenvolvidas por duas sociedades científicas de enfermagem muito importantes, como a Associação de Enfermagem Comunitária (AEC) e a Associação Latino-Americana de Escolas e Faculdades de […]See more -
ORIGINAL ARTICLE12-08-2024
Initial nipple damages in breastfeeding women: analysis of photographic images and clinical associations
Revista Brasileira de Enfermagem. 2024;77(1):e20220773
Abstract
ORIGINAL ARTICLEInitial nipple damages in breastfeeding women: analysis of photographic images and clinical associations
Revista Brasileira de Enfermagem. 2024;77(1):e20220773
DOI 10.1590/0034-7167-2022-0773
Views0See moreABSTRACT
Objective:
to analyze the initial nipple damage degree by breastfeeding practice and to associate findings with clinical manifestations of breastfeeding women.
Methods:
a retrospective, cross-sectional study with primary data and photographic images database from two randomized clinical trials. Photographic images were analyzed by two independent evaluators using the Nipple Trauma Score. For analysis, the chi-square, Mann-Whitney tests and Kappa coefficient were applied.
Results:
115 breastfeeding women and their respective 186 photographic images were analyzed. The degree of agreement of evaluators using the Nipple Trauma Score was 93.6%. The nipple pain score during breastfeeding was moderate and compromised more than 25% of the nipple surface area.
Conclusions:
assistance to breastfeeding women should prioritize nipple pain intensity instead of the nipple damage size.
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REVIEW12-08-2024
Interventions for Strengthening General Self-Efficacy Beliefs in College Students: An Integrative Review
- Lais Palotta Balderrama Gueroni ,
- Daniele Alcalá Pompeo ,
- Letícia Palota Eid ,
- Marcos Antonio Ferreira Júnior ,
- Carlos Alberto da Cruz Sequeira , [ … ],
- Luciano Garcia Lourenção
Abstract
REVIEWInterventions for Strengthening General Self-Efficacy Beliefs in College Students: An Integrative Review
Revista Brasileira de Enfermagem. 2024;77(1):e20230192
DOI 10.1590/0034-7167-2023-0192
- Lais Palotta Balderrama Gueroni ,
- Daniele Alcalá Pompeo ,
- Letícia Palota Eid ,
- Marcos Antonio Ferreira Júnior ,
- Carlos Alberto da Cruz Sequeira ,
- Luciano Garcia Lourenção
Views0See moreABSTRACT
Objective:
To assess the evidence regarding the effectiveness of interventions aimed at strengthening self-efficacy beliefs in college students.
Methods:
Integrative Review conducted on the Lilacs, PubMed, CinahL, Cochrane Collaboration Databases, Scopus, and PsycInfo databases. The methodological quality of the studies was assessed using tools proposed by the Joanna Briggs Institute, and the results were analyzed descriptively.
Results:
Out of the 10 selected studies, six demonstrated that interventions aimed at strengthening self-efficacy were effective (Levels of Evidence II and III), and four revealed contrary results (Levels of Evidence I and II). Programs aimed at enhancing self-efficacy should include content on positive mental health, psychoeducation strategies, cover a period of eight to twelve weeks, and consider the completion of homework assignments.
Conclusion:
The synthesis of evidence pointed to pathways for building an effective self-efficacy strengthening program to be implemented in universities.
- Lais Palotta Balderrama Gueroni
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REVIEW12-08-2024
Common mental disorders in hematopoietic stem cell transplant patients: a scoping review
- Ana Clara Paiva de Almeida ,
- Valéria Dantas de Azevedo ,
- Tássia Regine de Morais Alves ,
- Viviane Euzébia Pereira Santos ,
- Glauber Weder dos Santos Silva , [ … ],
- Isabelle Campos de Azevedo
Abstract
REVIEWCommon mental disorders in hematopoietic stem cell transplant patients: a scoping review
Revista Brasileira de Enfermagem. 2024;77(1):e20220581
DOI 10.1590/0034-7167-2022-0581
- Ana Clara Paiva de Almeida ,
- Valéria Dantas de Azevedo ,
- Tássia Regine de Morais Alves ,
- Viviane Euzébia Pereira Santos ,
- Glauber Weder dos Santos Silva ,
- Isabelle Campos de Azevedo
Views0See moreABSTRACT
Objective:
to map common recurrent mental disorders in patients undergoing hematopoietic stem cell transplantation.
Methods:
this is a scoping review carried out in January 2022 in electronic databases and repositories of dissertations and thesis. Studies that answered the research question, met the objective of the study and were available in full electronically, in any language, were included.
Results:
the sample consisted of 28 studies, 14 of which were published in the United States of America. The common mental disorders found were depressive, anxiety, post-traumatic stress and mood disorders. Twenty symptoms were mentioned, among the most prevalent are fatigue and sleep disorders/insomnia.
Conclusions:
the difficulty and importance of carrying out the differential diagnosis of these disorders were highlighted, since their symptoms can be confused with other health problems and have a strong potential to interfere with patients’ evolution.
- Ana Clara Paiva de Almeida
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ORIGINAL ARTICLE06-27-2019
Patient safety incidents identified by the caregivers of hospitalized children
- Letícia Maria Hoffmann ,
- Wiliam Wegner ,
- Cecilia Biasibetti ,
- Merianny de Ávila Peres ,
- Luiza Maria Gerhardt , [ … ],
- Márcia Koja Breigeiron
Abstract
ORIGINAL ARTICLEPatient safety incidents identified by the caregivers of hospitalized children
Revista Brasileira de Enfermagem. 2019;72(3):707-714
DOI 10.1590/0034-7167-2018-0484
- Letícia Maria Hoffmann ,
- Wiliam Wegner ,
- Cecilia Biasibetti ,
- Merianny de Ávila Peres ,
- Luiza Maria Gerhardt ,
- Márcia Koja Breigeiron
Views0See moreABSTRACT
Objective:
to analyze patient safety incidents identified by caregivers of hospitalized children.
Method:
a qualitative, exploratory-descriptive study was carried out with 40 caregivers of children hospitalized in three hospital institutions in the city of Porto Alegre, Rio Grande do Sul State, Brazil, from April to December 2016. Semi-structured, recorded and transcribed interviews were carried out in their entirety, submitted to a thematic analysis using the NVivo 11.0 software.
Results:
reports related to falls, infant feeding, patient/caregiver identification, medication process, communication, hand hygiene and hygiene of the hospital environment, spread of diseases, relations between caregivers and professionals and care processes/procedures were all cited.
Final considerations:
communication and the relations among caregivers and professionals are the main contributory factors for patient safety incidents, interfering with the quality of care. The participation of caregivers and engagement in child care may be strategies to be developed to promote a safety culture.
- Letícia Maria Hoffmann
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ORIGINAL ARTICLE09-16-2019
Tuberculosis: health care and surveillance in prisons
- Manuela Filter Allgayer ,
- Karine Zenatti Ely ,
- Graziela Hamann de Freitas ,
- Andréia Rosane de Moura Valim ,
- Roxana Isabel Cardozo Gonzales , [ … ],
- Lia Gonçalves Possuelo
Abstract
ORIGINAL ARTICLETuberculosis: health care and surveillance in prisons
Revista Brasileira de Enfermagem. 2019;72(5):1304-1310
DOI 10.1590/0034-7167-2018-0260
- Manuela Filter Allgayer ,
- Karine Zenatti Ely ,
- Graziela Hamann de Freitas ,
- Andréia Rosane de Moura Valim ,
- Roxana Isabel Cardozo Gonzales ,
- Suzane Beatriz Frantz Krug ,
- Lia Gonçalves Possuelo
Views0See moreABSTRACT
Objective:
To identify tuberculosis-related health care and surveillance actions in Prison Health Units.
Method:
Cross-sectional study, of quantitative, exploratory and descriptive character. We visited 13 Teams of Prison Health, and nurses and technicians were interviewed regarding epidemiological surveillance instruments, physical structure and materials.
Results:
Search for respiratory symptoms in admission was reported by 6 (46.2%) of the teams, and the smear microscopy was the most requested test. The Logbook of Respiratory Symptoms and the Logbook for Monitoring Tuberculosis Cases were used in 7 (53.8%) institutions. Two of them (15.4%) had a location for sputum collection and 1 (7.7%) had a radiographer. The Directly Observed Therapy was reported in 7 (53.8%) units.
Conclusion:
Health care actions related to the search for respiratory symptoms and Directly Observed Therapy should be expanded, as well as surveillance actions and recording in official documents of the National Tuberculosis Control Program.
- Manuela Filter Allgayer
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ORIGINAL ARTICLE03-07-2022
Adaptation and validation of the Advanced Practice Nursing Competency Assessment Instrument
- Flávia Carvalho Pena Dias ,
- Tamara Cristina Baitelo ,
- Beatriz Rosana Gonçalves de Oliveira Toso ,
- Pedro Sastre-Fullana ,
- Ana Railka de Souza Oliveira-Kumakura , [ … ],
- Renata Cristina Gasparino
Abstract
ORIGINAL ARTICLEAdaptation and validation of the Advanced Practice Nursing Competency Assessment Instrument
Revista Brasileira de Enfermagem. 2022;75(5):e20210582
DOI 10.1590/0034-7167-2021-0582
- Flávia Carvalho Pena Dias ,
- Tamara Cristina Baitelo ,
- Beatriz Rosana Gonçalves de Oliveira Toso ,
- Pedro Sastre-Fullana ,
- Ana Railka de Souza Oliveira-Kumakura ,
- Renata Cristina Gasparino
Views0See moreABSTRACT
Objective:
To adapt and validate the content of the Advanced Practice Nursing Competency Assessment Instrument (APNCAI) to Brazilian culture.
Methods:
This is a methodological study that followed the stages of translation, synthesis, back translation, evaluation by a committee of five specialists, pre-test with 31 nurses, and evaluation by the author of the original instrument. The Content Validity Index (minimum 0.90) and the modified Kappa (minimum 0.74) were calculated to evaluate the content.
Result:
In the first round of content evaluation, 18 items had to be altered because they did not reach the minimum values established. Three items have not reached a consensus in the second round and had to be sent to the author of the original version. In the pre-test, 13 items were returned to the specialists because they suffered content changes.
Conclusion:
The Advanced Practice Nursing Competency Assessment Instrument (APNCAI) – Brazilian version was cross-culturally adapted, and its content was validated.
- Flávia Carvalho Pena Dias
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REVIEW07-29-2020
Frailty syndrome in the elderly: conceptual analysis according to Walker and Avant
- Fabiana Maria Rodrigues Lopes de Oliveira ,
- Keylla Talitha Fernandes Barbosa ,
- Mayara Muniz Peixoto Rodrigues ,
- Maria das Graças Melo Fernandes
Abstract
REVIEWFrailty syndrome in the elderly: conceptual analysis according to Walker and Avant
Revista Brasileira de Enfermagem. 2020;73:e20190601
DOI 10.1590/0034-7167-2019-0601
- Fabiana Maria Rodrigues Lopes de Oliveira ,
- Keylla Talitha Fernandes Barbosa ,
- Mayara Muniz Peixoto Rodrigues ,
- Maria das Graças Melo Fernandes
Views0See moreABSTRACT
Objective:
To analyze the concept of “frailty syndrome” in the literature, according to the method proposed by Walker and Avant.
Methods:
It is a concept analysis, guided by the method proposed by Walker and Avant, made operational through an integrative literature review. The search in a scientific database was carried out using the descriptors: Frail elderly, syndrome, phenotype, geriatric assessment, and aging. The literary corpus comprised 66 studies. Results: The study found the antecedents and attributes (categorized as physical, sociodemographic, and behavioral/environmental) that integrate the signs and symptoms evidenced in the “frailty syndrome,” as well as the consequences of this concept. The variables were analyzed with emphasis on the conceptions that influence the frailty process of the elderly.
Conclusion:
The study demonstrated the complexity arising from the multifactorial genesis of the referred syndrome, emphasizing the specificities of the elderly’s frailty. However, we recommend conducting further research involving the phenomenon in question to understand the construct better.
- Fabiana Maria Rodrigues Lopes de Oliveira
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09-16-2019
Construct validation: coping with HIV/AIDS in Primary Health Care
- Révia Ribeiro Castro ,
- Sylvia Silva de Oliveira ,
- Illiana Rose Benvinda de Oliveira Pereira ,
- Wenysson Noleto dos Santos ,
- Sâmara Fontes Fernandes , [ … ],
- Richardson Augusto Rosendo da Silva
Abstract
Construct validation: coping with HIV/AIDS in Primary Health Care
Revista Brasileira de Enfermagem. 2019;72(5):1173-1181
DOI 10.1590/0034-7167-2018-0734
- Révia Ribeiro Castro ,
- Sylvia Silva de Oliveira ,
- Illiana Rose Benvinda de Oliveira Pereira ,
- Wenysson Noleto dos Santos ,
- Sâmara Fontes Fernandes ,
- Richardson Augusto Rosendo da Silva
Views0See moreABSTRACT
Objective:
To validate the construct and measure the trustworthiness of a questionnaire aimed at assessing HIV/AIDS coping actions developed by health professionals in Primary Health Care.
Method:
A methodological study carried out with 397 primary health care professionals in two municipalities in the Northeast region of Brazil. The construct validity was developed by the exploratory and confirmatory factor analysis, and the reliability analyzed by the reliability and reproducibility.
Results:
The validation determined six factors retention that composed the six domains of the questionnaire. Internal consistency was 0.91 and quality of the confirmatory analysis adjustment was 0.998 for Goodness of Fit Index. The domains presented Kappa values between 0.833 and 0.997.
Conclusions:
The final questionnaire was composed of 18 items and presented feasibility of application, and potential to evaluate actions for HIV/AIDS control in Primary Health Care.
- Révia Ribeiro Castro
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02-10-2020
Development of middle-range theories in nursing
- Tânia Alteniza Leandro ,
- Marília Mendes Nunes ,
- Iane Ximenes Teixeira ,
- Marcos Venícios de Oliveira Lopes ,
- Thelma Leite de Araújo , [ … ],
- Viviane Martins da Silva
Abstract
Development of middle-range theories in nursing
Revista Brasileira de Enfermagem. 2020;73(1):e20170893
DOI 10.1590/0034-7167-2017-0893
- Tânia Alteniza Leandro ,
- Marília Mendes Nunes ,
- Iane Ximenes Teixeira ,
- Marcos Venícios de Oliveira Lopes ,
- Thelma Leite de Araújo ,
- Francisca Elisângela Teixeira Lima ,
- Viviane Martins da Silva
Views0See moreABSTRACT
Objective:
To identify in the literature how Middle-Range Theories (MRT) are being developed in Nursing.
Method:
Integrative review on the databases Lilacs (Latin American and Caribbean Literature in Health Sciences), Scopus, Cinahl (Cumulative Index to Nursing and Allied Health Literature), Web of Science and PubMed portal, using the keywords middle range theory and nursing, as well its Portuguese correspondents (Lilacs), and the Boolean operator AND. The sample included 25 articles.
Results:
All articles presented concepts related to MRT. Most developed a synthesis picture. Some theories have formulated specific propositions, hypotheses, and names. Only 16 articles cited the methodological framework, while 22 used theories or models for theoretical foundation and 11 carried out literature reviews.
Final considerations:
The development of MRT included the presentation of fundamental concepts, synthesis, propositions, hypotheses and specific name. The MRT is recognized as a way of developing knowledge to guide the nursing practice.
- Tânia Alteniza Leandro
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REVIEW08-20-2021
Assessment of patient safety culture in Brazilian hospitals through HSOPSC: a scoping review
- Marcela Moreira Nascimento Prieto ,
- Renata Elizabete Pagotti da Fonseca ,
- Silvia Helena Zem-Mascarenhas
Abstract
REVIEWAssessment of patient safety culture in Brazilian hospitals through HSOPSC: a scoping review
Revista Brasileira de Enfermagem. 2021;74(6):e20201315
DOI 10.1590/0034-7167-2020-1315
- Marcela Moreira Nascimento Prieto ,
- Renata Elizabete Pagotti da Fonseca ,
- Silvia Helena Zem-Mascarenhas
Views0See moreABSTRACT
Objectives:
to describe, from literature, the characteristics of patient safety culture in Brazilian hospitals that applied the Hospital Survey on Patient Safety Culture.
Methods:
this is a scoping review. A search was performed in the databases LILACS, PubMed, SciELO, CINAHL, Web of Science, Scopus and in the CAPES Dissertations and Theses Database in September and October 2020.
Results:
thirty-six studies were identified. Nine studies identified strengthened areas such as: “teamwork within the units”, “expectations of supervisor/boss and actions promoting safety”, “organizational learning”, “support of hospital management for patient safety” and “frequency of report of events”. As a critical area, the dimension “non-punitive response to error” was evidenced in 30 of 36 studies.
Conclusions:
the identification of areas of strength and critical areas of safety culture is relevant to encourage improvement of patient safety problems in an institution.
- Marcela Moreira Nascimento Prieto
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ORIGINAL ARTICLE11-12-2022
Low-laser light therapy in venous ulcer healing: a randomized clinical trial
Revista Brasileira de Enfermagem. 2022;75(3):e20210396
Abstract
ORIGINAL ARTICLELow-laser light therapy in venous ulcer healing: a randomized clinical trial
Revista Brasileira de Enfermagem. 2022;75(3):e20210396
DOI 10.1590/0034-7167-2021-0396
Views0See moreABSTRACT
Objectives:
to compare the effect of adjuvant low-laser light therapy versus conventional treatment alone on venous ulcer healing.
Methods:
this is a randomized clinical trial with 40 patients randomized equally to a control group (topical and compressive treatment) and intervention group (adjuvant low-laser light therapy). Outcomes of interest were Wound Healing: Secondary Intention and Tissue Integrity: Skin & Mucous Membranes, as described in the Classification of Nursing Outcomes/NOC.
Results:
groups with similar sociodemographic and clinical characteristics. Eighty-two ulcers were assessed, with an average duration of 1 to 5 years, in 1,066 nursing consultations, with a statistically significant difference in the time and number of healed ulcers (intervention group). There was a significant improvement in the nursing outcomes under study and in eight clinical indicators.
Conclusions:
low-laser light therapy improves and reduces tissue regeneration time, contributing to advances in wound treatment.
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