This article describes the development of pressure ulcer knowledge and management in Brazil. Recent studies have shown that pressure ulcers are a significant problem in Brazil, and several local and international organisations have recognised the important role nurses play in prevention and care. As a result, nursing education and resources have improved and evaluating the risk and occurrence of pressure ulcers has become a method of establishing indicators of quality care in Brazil.

INTRODUCTION
Pressure ulcers in elderly patients and those with chronic diseases have become a serious problem in Brazil, both within hospitals and patients' homes. Brazil is a large country with huge variations between the different regions and the lack of a national agency makes it very difficult to estimate the total incidence of pressure ulcers. However, in clinical practice the prevalence and incidence of pressure ulcers in Brazil are still high, mainly among more debilitated patients and those who require an extended recovery period such as neurosurgical patients, quadriplegic patients and geriatric patients with hip fractures.

The World Health Organization (WHO) uses the incidence and prevalence of pressure ulcers as an indicator of the quality of patient care services and the use of efficient prevention measures and treatments has become paramount[1], especially since approximately 95% of pressure ulcer cases can be avoided.
The National Pressure Ulcer Advisory Panel (NPUAP) estimates that approximately 60,000 people in the US die annually due to complications generated by pressure ulcers and associated expenses are estimated at between $2,000 and $25,000 per individual per year[2]. In Brazil, studies that estimate the costs of pressure ulcer incidents have yet to be performed, especially in regard to those acquired in hospital environments.


Incidence
In recent years, studies in Brazil have been carried out on adult critical care inpatients in an attempt to estimate the incidence and prevalence of pressure ulcers. The global incidence of pressure ulcers in Brazilian hospitals has been put at 39.8%[3] with the highest rates found in intensive care units. It has been identified that sepsis and length of stay are factors associated with ulcers in bedridden patients[4].

In Brazil, pressure ulcers frequently occur in areas of bony prominence. Approximately 60% develop in the sacral region, compared to 15% in the ischium, greater trochanter and heel regions[5]. These areas are more commonly affected as the patient's body weight is concentrated on them during any extended recovery period.


WOUND CARE NURSING IN BRAZIL
In Brazil, nurses have been gradually developing a systematic and therapeutic approach to evaluating and implementing wound care treatment and have achieved professional autonomy in the area. Wound care is a specialty within nursing and is recognised by the Brazilian Society of Dermatology Nursing (SOBENDE) as well as by the Brazilian Association of Stomatherapy (SOBEST).

Dermatological nursing
Dermatological nursing has been in constant development through nurses working directly with patients on dressings or preventive areas of medicine, such as education and research.

Stomatherapy
As a specialty, stomatherapy first appeared at the end of the 1950s, yet was only recognised as being exclusive to nurses by the World Council of Enterostomal Therapists (WCET) in 1980. In Brazil, the first stomatherapy nursing course was held at the Nursing School of the University of São Paulo in 1990. Today, 10 nursing courses, which have received approval or are in the process of approval by SOBEST and WCET, are available.

The role of the nurse
Despite the breadth of their professional responsibilities nurses still face innumerous difficulties when attempting to provide specialist care, such as sourcing new knowledge and establishing prevention procedures.

These difficulties have there origins not only in the history of nursing, but also within nursing education, the round of daily nursing tasks and institutional pressures, for example, specialist nurses are involved in patient care, education and research and each may have a caseload of more than 40 patients.

Early in the development of nurse specialist training in Brazil, attention was focused exclusively on caring for ostomy patients and then on patients with wounds and incontinence. It has taken time for Brazilian nurses to be recognised for their role in the prevention and treatment of pressure ulcers.