Pressure Injuries in Dependent Individuals within Primary Care: A Descriptive Study

Introduction. Pressure injuries represent a prevalent and serious health issue among dependent individuals, especially within the primary care context. These injuries contribute to increased morbidity, diminished quality of life, and greater healthcare resource utilization. Accurate and comprehensive clinical records are essential not only for guiding individual patient care but also for supporting scientific research. They enable the identification of risk factors, monitoring of outcomes, and development of evidence-based interventions. The Aim of this study is to analyse the informatic nursing records of dependent persons in a Portuguese Primary Health Care Unit (PHCU), within the scope of the prevention and treatment of pressure ulcers/injuries (PU/PI). Methods. Retrospective analysis of electronic health record database from 112 patients registered in the “Dependents Program” of the Informatic System SClínico® of a Portuguese Primary Health Care Unit during 2019. Beyond sociodemographic characterization, the data analysis included the following variables: self-care level; PU/PI risk; co-morbidities; nutritional risk; PU/PI classification, anatomical location, assessment, and type of treatments performed; pain and the family caregiver’s “ability” and “knowledge” to prevent PU/PI. Results. During 2019, 80.4% of the participants had the self-care level recorded and 83.0% had the PU/PI risk assessment recorded. The nutritional risk assessment was not recorded in 90.2% of the participants. The PU/PI assessment through RESVECH 2.0 was registered in 72.2% of the participants. The treatment implemented and the pain assessment were documented in a residual way. Discussion and Conclusions. The findings reveal notable strengths and gaps in the documentation practices related to pressure injury prevention and management in primary care. While a majority of participants had their self-care level and PU/PI risk assessments recorded, critical areas such as nutritional risk assessment were largely neglected. Given the well-established link between nutrition and skin integrity, this represents a significant oversight. The use of the RESVECH 2.0 tool for PU/PI assessment was observed in great percentage of participants, indicating moderate integration of standardized assessment tools into clinical practice. However, the documentation of both treatment interventions and pain assessment was minimal, suggesting these essential aspects of care are not being systematically recorded. These findings underscore the need to strengthen comprehensive and consistent record-keeping, as incomplete documentation can hinder both the continuity of care and the generation of robust scientific evidence.