Keywords

app, clinical protocols, disease prevention, mobile application, nursing intervention, pressure injury, pressure injury staging

 

Authors

  1. Salome, Geraldo Magela PhD, RN
  2. Ferreira, Lydia Masako MD, PhD

ABSTRACT

OBJECTIVE: This descriptive study describes the planning and development of a mobile application (app) for prevention and treatment of pressure injuries for use by providers in a university research center. The app delineates risk factors for pressure injury development, provides an evaluation of the wound, recommends wound cleansing procedures, performs pressure injury staging, and recommends treatment interventions.

 

METHODS: A mobile app was developed using a contextualized instructional design, which involves a constructivist proposal and planning, developing, and applying specific didactic situations, thus incorporating mechanisms that favor contextualization. A literature search was conducted to identify relevant studies for the construction of the mobile app. The development process involved the selection of app tools, definition of the navigation structure, and planning of the environment configuration. The environment for downloading the app software on the Internet and installing it on the mobile device was created.

 

MAIN RESULTS: The literature search yielded 18 articles, 2 books, and 1 master's degree thesis. A mobile app was created with an easy-to-use graphic interface. The app stores the patient's demographic characteristics and provides an evaluation of his/her wound, a list of risk factors for pressure injury development, wound cleansing procedures, and treatment interventions.

 

CONCLUSIONS: The developed app may be useful in clinical practice, helping to prevent pressure injuries and promote select nursing interventions for the treatment of patients with pressure injury.

 

Article Content

INTRODUCTION

Advances in healthcare are associated with increased life expectancy, enhancing the survival of patients with serious conditions, especially chronic diseases. Many patients who are bedridden develop pressure injuries and other types of lesions.1,2

 

A pressure injury is localized damage to the skin and/or underlying soft tissue; it can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear.3,4 International studies report that pressure injury incidence ranges from 1.9% to 35%, and prevalence ranges from 11.1% to 31%.5-8 These statistics may be reduced through preventive measures.5-9 Pressure injury management represents a significant resource cost to health institutions, and this economic aspect is fundamental to the intervention decision-making process.10,11

 

Educational technologies in the prevention and treatment of pressure injuries (such as applications [apps] for mobile devices and online courses, among others) are a viable alternative for the delivery of health education. They present a new means of health promotion through the participation of the population in a shared construction of knowledge, providing the patient and family with reading materials, reinforcing verbal instructions, and guiding decision-making in the prevention and treatment of pressure injuries on a daily basis.12-14

 

The construction of a digital environment for nurses to provide care to patients with pressure injuries can be a useful strategy for training, diagnosis, and therapeutic management.15 The use of mobile apps as educational, care management, and diagnostic tools is innovative and enhances interest and motivation to learn. Mobile devices hosting these apps are used by 45% to 85% of health professionals worldwide and are now more commonly used than books and journals.15-20

 

Given this knowledge, the aim of this study was to develop a mobile app for use by healthcare providers in the prevention and treatment of pressure injuries.

 

METHODS

This descriptive study was approved by the Research Ethics Committee of the Dr Jose Antonio Garcia Coutinho School of Medical Sciences, Sapucai Valey University, Brazil (approval no. 1.417.426).

 

Analysis

A literature review to identify the educational problem and illuminate a solution was carried out using various databases: the Cochrane Library, Scientific Electronic Library Online (SciELO), Latin American and Caribbean Literature in Health Sciences (LILACS), US National Library of Medicine (MEDLINE), International Nursing Index (INI), and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The search was performed using the following keywords: "pressure ulcer," "prevention and control," "mobile applications," and "clinical protocols."

 

All articles including the definition or classification of pressure injuries, the Braden scale, risk factors for pressure injury development, nursing care of patients at risk of pressure injury development, and types of dressings used in the treatment of pressure injuries were included in the study. Other inclusion criteria were primary studies directly related to the topic, available as full text, and written in Portuguese, English, or Spanish. The exclusion criteria were books, book chapters, theses, dissertations, monographs, technical reports, and articles that, after reading the abstract, did not meet the inclusion criteria, as well as duplicate publications. The search was not limited to a specific time period.

 

Based on the results, the technological infrastructure needed and the study flowchart were then defined (Figure 1).

  
Figure 1 - Click to enlarge in new windowFigure 1. FLOWCHART FOR CONSTRUCTION OF THE MOBILE APPLICATION

Design and Development

Study authors developed a mobile app in Brazilian Portuguese for use by healthcare providers in the prevention and treatment of pressure injuries and in the training and education of healthcare professionals and students. It was developed for Android mobile devices using Android Studio, made available by Google. The app was initially developed for Android devices because they are more affordable than Apple devices and therefore more popular in Brazil. The assumption was that a greater number of health professionals and students might have access to an Android app over an iOS app. After its validation, the app will also be made available for other operating systems.

 

The developers used a contextualized instructional design to develop the app, which involves a constructivist proposal and intentional actions of planning, developing, and applying specific didactic situations, incorporating mechanisms that favor contextualization.15,21 The design process involved the planning and production of didactic content, the selection of topics and writing tasks, and media and layout design. Topics were divided into subtopics and connected by hyperlinks. During the development process, app tools were selected, the navigation structure was defined, and the environment configuration was planned by the authors. An environment for downloading the app software on the Internet and installing it on mobile devices was created.

 

RESULTS

The selection of studies, which served as the basis for the construction of the mobile app, included 18 articles, 2 books, and a master's degree thesis.

 

The home page of the mobile app has 2 buttons: "Prevention of Pressure Injuries" and "Treatment of Pressure Injuries" (Figure 2). Both the prevention and treatment algorithms have a menu item called "New Patient" for providers to register patients new to the app. The menu button "Filter by" allows users to search the content of patients already registered in the system. This menu displays the items "All Patients" and "Search Patients," allowing the user to locate records of registered patients (Figure 2). The "New Patient" item in the navigation bar at the bottom opens a patient registration form, containing mandatory fields to be filled with basic patient information, including full name, sex, and date of birth (Figure 2).

  
Figure 2 - Click to enlarge in new windowFigure 2. THE GRAPHICAL USER INTERFACELeft, the home page provides access to both the Prevention and Treatment algorithms. Center, the menu button "Filter by" allows searches for patients already registered in the system. Right, patient registration form.

On the next page, the algorithm for prevention of pressure injuries begins with a clinical assessment (Figure 3). The selection of the Braden scale button directs the provider to the Braden scale for Predicting Pressure Sore Risk (Figure 3). The sum of numerical scores on the Braden scale subscales (ie, sensory perception, activity, mobility, moisture, nutrition, and friction and shear) indicates the level of risk as follows: no risk, 19 to 23; at risk, 15 to 18; moderate risk, 13 to 14, high risk, 10 to 12; and very high risk, 6 to 9. Nursing interventions are then recommended based on the risk classification (Figure 4). These data are stored in the mobile device's memory.

  
Figure 3 - Click to enlarge in new windowFigure 3. THE PREVENTION GRAPHICAL USER INTERFACELeft, the algorithm for prevention of pressure injuries begins with the clinical assessment of patients. Right, assessment of risk of pressure injury development using the Braden scale.
 
Figure 4 - Click to enlarge in new windowFigure 4. SAMPLE RECOMMENDATIONS OF NURSING INTERVENTIONS BASED ON RISK CLASSIFICATION

Clicking "Finish" on the navigation bar opens the Treatment of Pressure Injuries page. The first step of this algorithm assesses wound size; wound margin; types of tissue present in the wound bed; type, amount, and color of exudate; and presence of infection signs. The next step guides the health professional in cleansing the wound site according to the type of tissue present in the wound bed (Figure 5). Pressure injury staging is then performed (Figure 5). In the last step, the mobile app recommends a treatment according to the pressure injury stage (Figure 6).

  
Figure 5 - Click to enlarge in new windowFigure 5. THE GRAPHICAL USER INTERFACE: OTHER FEATURESLeft and center, examples of instructions for cleansing the wound site according to the type of tissue present in the wound bed. Center and right, pressure injury staging.
 
Figure 6 - Click to enlarge in new windowFigure 6. RECOMMENDATION OF TREATMENTS ACCORDING TO PRESSURE INJURY STAGE

The app for registration of the mobile app software was made to the Brazilian National Institute of Industrial Property, Ministry of Development, Industry and Foreign Trade (application no. BR 5120160011670). Currently, the mobile app is available at http://fnunes.azurewebsites.net/UPP_Inicial.asp.

 

DISCUSSION

The accelerated scientific and technological development in the health sector has created new ways of building knowledge about wound management. Advances in computational technology are expected to improve organizational processes at all levels in the coming years, providing operational and strategic benefits to institutions and nursing practice.22

 

Smartphones play an important role in the clinical practice of professionals caring for patients with a lesion of any etiology; they are an important tool because most people have one, and they are widely available because of their portability. The current trend toward the use of smartphones may be attributed to their ease of use, rapid access to the Internet, and multiple functions through apps.

 

An app has a specific function and is able perform certain tasks. The app described in this article allows the health professional to select the type of dressing most appropriate for each wound to promote wound healing and prevent pressure injury recurrence. This technology can also be used as a teaching and learning resource. The app has a user-friendly graphical interface. The content is clearly described in a simple, explanatory fashion, with attractive illustrations and sufficient information for the health professional to provide safe evidence-based care.

 

The project interface consists of a database composed of 2 registers. The main register contains the patient's demographic and clinical characteristics as assessed by the health professional. The second register is linked to the main register and stores individual patient information about the wound and risk factors for pressure injury development. Clinical information on 1 or more ulcers can be recorded. It also retains information on the Braden scale scores, preventive measures, and nursing interventions recommended based on the Braden scale total score and presence of intrinsic and extrinsic risk factors for pressure injury development.

 

A mobile app for teaching health professionals how to measure central venous pressure was developed and evaluated in a previous study.15 The authors concluded that the use of multimedia favors a motivating and dynamic environment by integrating images and text into an app as a mobile, autonomous approach to self-directed learning. The results demonstrated the viability of multimedia as pedagogical tools for practice and open perspectives for the use of available technology in nursing education as new ways of learning.15

 

A mobile app has been created to classify pressure injuries through image processing on mobile devices.23 In that app, a photograph of the pressure injury is uploaded into the system, which processes the image and suggests the probable stage of the injury based on the implemented algorithm.23 In this study, after the patient is registered, the characteristics of the pressure injury are entered into the system. The app shows the evaluation of the pressure injury, wound cleansing procedures are recommended, the pressure injury is staged, and treatment interventions are recommended according to the type of tissue present in the wound bed and presence of exudate.

 

A software tool has been developed to support the continuing education of health professionals and educational practices on diabetes mellitus.24 Other apps have been built to assess the risk and evolution of pressure injuries in intensive care unit patients.20 That tool was assessed by 15 intensive care unit nurses who considered 58.2% of its items of adequate quality.20

 

When building an app, clinicians should be concerned with providing clear content and sufficient information and presenting the material in a concise and easy-to-read style, avoiding ambiguity, to produce the expected learning outcomes. The choice and presentation of content should take into account the ability to activate students' prior knowledge.25 Besides enhancing motivation, images contribute to the acquisition of intuitive knowledge and promote the understanding of concepts that are more difficult to comprehend in a textual format.25

 

CONCLUSIONS

This study described the planning and development of a mobile app for the prevention and treatment of pressure injuries. The validity and reliability of the app have yet to be tested. Also, the use of Braden subscores should be used in risk assessment for pressure injury development. This app may be useful in clinical practice to help prevent pressure injuries and select nursing interventions for the treatment of pressure injury patients, as well as in nursing education.

 

REFERENCES

 

1. Wada A, Teixeira Neto N, Ferreira MC. Pressure sores. Rev Med (Sao Paulo) 2010;89:170-7. [Context Link]

 

2. Moraes JT, Borges EL, Lisboa CR, Coredeiro DC, Rosa EG, Rocha NA. Concept and rating of pressure injury: update of the National Pressure Ulcer Advisory Panel. Enferm Cent O Min 2016;6:2292-306. [Context Link]

 

3. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: revised pressure injury staging system. J Wound Ostomy Continence Nurs 2016;43:585-97. [Context Link]

 

4. Santos CT, Almeida Mde A, Lucena Ade F. The nursing diagnosis of risk for pressure ulcer: content validation. Rev Lat Am Enfermagem 2016;24. [Context Link]

 

5. Dutra RA, Salome GM, Alves JR, et al. Using transparent polyurethane film and hydrocolloid dressings to prevent pressure ulcers. J Wound Care 2015;24:268-75. [Context Link]

 

6. Dutra RA, Salome GM, Leal LM, et al. Cost comparison of pressure ulcer preventive dressings: hydrocolloid dressing versus transparent polyurethane film. J Wound Care 2015;25:635-40. [Context Link]

 

7. Sardo PM, Simoes CS, Avarelhao JJ, et al. Analyses of pressure ulcer incidence in inpatient setting in a Portuguese hospital. J Tissue Viability 2016;25:209-15. [Context Link]

 

8. De Lima EL, de Brito MJ, de Souza DM, Salome GM, Ferreira LM. Cross-cultural adaptation and validation of the neonatal/infant Braden Q risk assessment scale. J Tissue Viability 2016;25:57-65. [Context Link]

 

9. Niederhauser A, VanDeusen Lukas C, Parker V, et al. Comprehensive programs for preventing pressure ulcers: a review of the literature. Adv Skin Wound Care 2012;25:167-88; quiz 189-90. [Context Link]

 

10. Silva AJ, Pereira SM, Rodrigues A, et al. Economic cost of treating pressure ulcers: a theoretical approach. Rev Esc Enferm USP 2013;47:971-6. [Context Link]

 

11. Andrade CC, Almeida CF, Pereira WE, Alemao MM, Brandao CM, Borges EL. Costs of topical treatment of pressure ulcer patients. Rev Esc Enferm USP 2016;50:295-301. [Context Link]

 

12. Benevides JL, Coutinho JF, Pascoal LC, et al. Development and validation of educational technology for venous ulcer care. Rev Esc Enferm USP 2016;50:309-16. [Context Link]

 

13. Reberte LM, Hoga LA, Gomes AL. Process of construction of an educational booklet for health promotion of pregnant women. Rev Lat Am Enferm 2012;20:101-8. [Context Link]

 

14. Rajpaul K, Acton C. The use of smart technology to deliver efficient and effective pressure-damage education. Br J Nurs 2015;24 Suppl 20:S4-S12. [Context Link]

 

15. Galvao EC, Puschel VA. Multimedia application in mobile platform for teaching the measurement of central venous pressure. Rev Esc Enferm USP 2012;46 Spe No:107-15. [Context Link]

 

16. Oliveira TR, Costa FM. Development of mobile application for reference to vaccination in Brazil. J Health Inform 2012;4:23-7. [Context Link]

 

17. Perreira FG, Silva DV, Sousa LM, Frota NM. Building a digital application for teaching vital signs. Rev Gaucha Enferm 2016;37. [Context Link]

 

18. Langemo D, Spahn JG. A multimodality imaging and software system for combining an anatomical and physiological assessment of skin and underlying tissue conditions. Adv Skin Wound Care 2016;29:155-63. [Context Link]

 

19. Dantas UI, Santos SR, Brito SS, Virgolino JL. Perceptions of the managers about the application-treaty for health. J Nurs UFPE 2013;7:438-44. [Context Link]

 

20. Vitoriano AM, Dell'Acqua MC, Silva CP, Oliveira JS, Castro MC. Software evaluation to pressure ulcer risk and evolution in intensive therapeutic care. J Nurs UFPE 2016;10:2369-75. [Context Link]

 

21. Filatro A. Contextualized Instructional Design. Sao Paulo, Brazil: SENAC, 2007. [Context Link]

 

22. Cruz NS, Soares DK, Bernardes A, Gabriel CS, Pereira MC, Evora YD. Nursing undergraduates' technical competence in informatics. Rev Esc Enferm USP 2011;45 Spec No:1595-9. [Context Link]

 

23. Tibes CM, Cherman EA, Souza VM, Evora YD, Zem-Mascarenhas SH. Image processing in mobile devices to classify pressure injuries. J Nurs UFPE Online 2016;10:3840-7. [Context Link]

 

24. Duran EC, Cocco MI. Educational software about diabetes mellitus to health professionals: elaboration and development stages. Rev Lat Am Enferm 2003;11:104-7. [Context Link]

 

25. Corradi MI, Silva SH, Scalabrin EE. Virtual objects to support the teaching-learning process of physical examination in nursing. Acta Paul Enferm 2011;24348-53. [Context Link]