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Escalas de avaliação do risco de lesão da pele em recém-nascidos pré-termo : Scoping review
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Introdução: Os recém-nascidos pré-termo apresentam elevada vulnerabilidade cutânea, o que potencia o risco de desenvolvimento de lesões cutâneas, principalmente em unidades de cuidados intensivos neonatais. A utilização de instrumentos específicos de avaliação do risco
de lesão da pele permite uma abordagem sistematizada, padronizada e a implementação de medidas preventivas.
Objetivos: Descrever e refletir criticamente sobre o percurso formativo desenvolvido no
âmbito do Curso de Mestrado em Enfermagem de Saúde Infantil e Pediátrica; mapear e identificar as escalas utilizadas para avaliar o risco de lesão da pele em recém-nascidos prétermo em contexto de cuidados neonatais.
Metodologia: A parte I consiste numa reflexão descritiva sobre o percurso formativo em
estágio; a parte II consiste numa scoping review, baseada no protocolo do Joanna Briggs Institute. A pesquisa foi realizada em fevereiro de 2026 nas bases de dados PubMed,
CINAHL Complete, MEDLINE Complete, na plataforma ESBCOhost, no RCAAP e Rimas,
sem horizonte temporal, em português, inglês e espanhol. A amostra final incluiu nove
estudos e uma dissertação de mestrado.
Resultados: Foram identificados diferentes instrumentos de avaliação do risco de lesão
cutânea em recém-nascidos, destacando-se as escalas Neonatal Skin Risk Assessment Scale
(NSRAS) e a ISSA. A evidência demonstra que estes instrumentos facilitam a identificação
precoce de recém-nascidos vulneráveis e a implementação de estratégias preventivas adequadas.
Conclusão: A utilização de escalas estruturadas constitui uma estratégia fundamental na prática de enfermagem neonatal, contribuindo para a uniformização dos cuidados, a tomada de decisão clínica e a melhoria da qualidade e segurança dos cuidados prestados ao recémnascido
pré-termo.
Palavras-chave: recém-nascido pré-termo; avaliação de risco; avaliação em enfermagem; cuidados com a pele; enfermagem neonatal
Abstract Introduction: Preterm newborns exhibit high skin vulnerability, increasing the risk of developing skin injuries, particularly in neonatal intensive care units. The use of specific risk assessment instruments allows for a systematized and standardized approach, supporting the implementation of preventive measures and enhancing the quality of nursing care. Objectives: To describe and critically reflect on the training pathway developed within the Master’s Degree in Child and Pediatric Health Nursing; to map and identify the scales used to assess the risk of skin injury in preterm newborns in neonatal care settings. Methodology: Part I consists of a descriptive reflection on the clinical training experience; Part II consists of a scoping review based on the Joanna Briggs Institute protocol. The literature search was conducted in February 2026 across the PubMed, CINAHL Complete, and MEDLINE Complete databases and the EBSCOhost platform, as well as RCAAP and RIMAS. No time limits were applied, and studies in Portuguese, English, and Spanish were included. The final sample is comprised of nine studies and one master's dissertation. Results: Different skin injury risk assessment instruments were identified, most notably the Neonatal Skin Risk Assessment Scale (NSRAS) and the ISSA scale. Evidence shows that these tools facilitate the early identification of vulnerable newborns and support the implementation of appropriate preventive strategies. Conclusion: The use of structured skin injury risk assessment instruments is a fundamental strategy in neonatal nursing practice, contributing to the standardization of care, supporting clinical decision-making, and improving the quality and safety of care provided to preterm newborns. Keywords: Preterm infants; risk assessment; skin care; nursing assessment, neonatal nursing
Abstract Introduction: Preterm newborns exhibit high skin vulnerability, increasing the risk of developing skin injuries, particularly in neonatal intensive care units. The use of specific risk assessment instruments allows for a systematized and standardized approach, supporting the implementation of preventive measures and enhancing the quality of nursing care. Objectives: To describe and critically reflect on the training pathway developed within the Master’s Degree in Child and Pediatric Health Nursing; to map and identify the scales used to assess the risk of skin injury in preterm newborns in neonatal care settings. Methodology: Part I consists of a descriptive reflection on the clinical training experience; Part II consists of a scoping review based on the Joanna Briggs Institute protocol. The literature search was conducted in February 2026 across the PubMed, CINAHL Complete, and MEDLINE Complete databases and the EBSCOhost platform, as well as RCAAP and RIMAS. No time limits were applied, and studies in Portuguese, English, and Spanish were included. The final sample is comprised of nine studies and one master's dissertation. Results: Different skin injury risk assessment instruments were identified, most notably the Neonatal Skin Risk Assessment Scale (NSRAS) and the ISSA scale. Evidence shows that these tools facilitate the early identification of vulnerable newborns and support the implementation of appropriate preventive strategies. Conclusion: The use of structured skin injury risk assessment instruments is a fundamental strategy in neonatal nursing practice, contributing to the standardization of care, supporting clinical decision-making, and improving the quality and safety of care provided to preterm newborns. Keywords: Preterm infants; risk assessment; skin care; nursing assessment, neonatal nursing
Descrição
Palavras-chave
Avaliação de risco Cuidados da pele Enfermagem neonatal Pele - lesões Recém nascido prematuro Revisão scoping Infant premature Neonatal nursing Risk assessment Scoping review Skin - injuries Skin care