APPLICATION OF THE DIAPER USE RATING SCALE IN A MEDICAL CLINIC OF A UNIVERSITY HOSPITAL

Objetivos: aplicar a escala de avaliação do uso fraldas e absorventes (AUFA) nos pacientes internados na clínica médica; identificar e analisar os resultados dessa aplicação, o perfil sociodemográfico dos pacientes em vogo bem como repercussões à pele relacionadas ao uso de absorventes e fraldas. Método: estudo observacional transversal, descritivo e exploratório, realizado no setor de clínica médica do Hospital Universitário Clementino Fraga Filho (HUCFF/UFRJ), no período de novembro de 2019 a fevereiro de 2020, com amostra por conveniência de 46 pacientes. Ocorreu aplicação de ficha para levantamento de dados gerais e, após, a AUFA, que identificou as seguintes variáveis: condições da pele, envelhecimento da pele, capacidade cognitiva, capacidade motora e incontinências. Resultados: todos os 46 pacientes encontravam-se em uso de fralda, sendo metade mulheres e a outra metade homens, em grande maioria composta de idosos e sem diagnóstico de incontinência. Diante da aplicação e análise da AUFA, apenas 18 pacientes (39,14%) tinham indicação para uso de fraldas. Com o uso inadequado da fralda, 27 pacientes apresentaram lesão de pele decorrente de umidade, situação que se justificou pela ausência da observação de cuidados sistematizados para prevenção e tratamento de dermatite associada à incontinência nos pacientes avaliados. Conclusão: indica-se o uso da escala AUFA para identificar os pacientes que necessitam usar fralda, delimitando cuidados com seu manejo e prevenindo, assim, complicações e agravamentos da incontinência.


INTRODUCTION
The object of this study is the nursing actions related to the management of incontinence in relation to the use of absorbent devices and diapers, in addition to the prevention of dermatitis associated with incontinence in patients admitted to the internal medicine sector of a university hospital located in the city of Rio de Janeiro.
Absorbent devices for adult use are considered in the scientific literature as tools added to health care. From this perspective, its incorporation into health care demands clinical judgment and constant reassessment of care practices.
The nurse needs to be grounded and instrumentalized in the proper indication and continuity regarding the use of these devices in clinical practice, aware that this practice brings benefits and harms, such as incontinence-associated dermatitis (IAD), pressure injury, urinary infection , worsening of incontinence, among others 1-6 . In this sense, it is necessary to use scales and assessment instruments to support conscious decision-making based on scientific evidence by nurses regarding the use of pads and diapers [1][2][3][4][5][6] .
Thus, the evaluation scale for the use of diapers and absorbent products (AUFA) is adequate for being a systematic tool for indicating and evaluating the need for the use of absorbent devices, as well as helping to implement preventive measures for IAD, according to the determination of the patient's risk score [1][2][3][4][5][6] .
Application of the diaper use rating scale in a medical clinic of a university hospital Furthermore, when applying this scale, there is a score with an algorithm that helps and supports the choice of the appropriate absorbent device. Thus, if the final score is less than 11, there is no indication for the use of absorbent devices, and the use of external utensils, such as bedpans, urinals or toilets, is suggested. In this case, urinary or fecal loss is absent or less than 50 mL a day, associated with preserved cognitive capacity 1 .
However, if the result is greater than or equal to 11 points and less than 14 points, it is indicated that there is urinary or fecal loss between 50 and 900 mL per day, correlated with partial cognitive deficit, therefore, there is a need to use absorbents 1 . Finally, if a quotient greater than or equal to 14 points on the AUFA scale is reached, it is revealed that there is urinary or fecal loss greater than or equal to 900 mL per day, with severe cognitive deficit. Therefore, it is recommended to use diapers 1 .
Therefore, the AUFA scale guides nurses' decision-making, enabling the planning of systematized and individualized care, with the main elements analyzed being: cognitive and motor capacity, degree of incontinence, patient and caregiver preferences, number of exchanges and conditions of skin -aging and skin integrity 1-6 .
It is worth remembering that the breakdown of skin integrity represents a health problem that can directly interfere with people's quality of life, functional capacity, autonomy and independence. When associated with any chronic diseases, it further increases the vulnerability to infectious pathological processes that can culminate in hospitalization. Thus, prevention is the best alternative, and health professionals, especially nurses, are responsible for preventive interventions and early treatment of associated injuries 7 .
It is worth noting that in recent years, with technological advances in health, there has been a significant increase in the life expectancy of the world population, and, therefore, a change in the profile of patients under health care, with more advanced ages, suffering from chronic diseases and risk for skin lesions [6][7][8] .
With regard to urinary, fecal and double (urinary and fecal) incontinence, the use of diapers or pads can be considered responsible for the emergence of dermatological problems and expansion of incontinence episodes. Thus, the indication for such use must be individually evaluated by the nurse through scientific strategies. The choice of the absorbent device must occur according to the analysis of the patient's characteristics, such as weight and height, as well as the type of incontinence 9 .
Thus, the type, shape, capacity and absorption speed of the absorbent or diaper and the saturation period, odor inhibitors and the need for changes are points to be considered when choosing the device, according to the demand of the client's profile. 9 However, in everyday practice, the use of this individual assessment is not routine in inpatient units. It is not possible to determine whether the parameters designated by manufacturers as an indication of use for each subgroup are in line with the technical parameters of the International Continence Society (ICS). Therefore, the use and empirical indication can have negative consequences for the patient and high cost for the health institution 9 .
In this sense, the following question was delimited as a guiding question: how is the indication for the use of diapers and sanitary pads by applying the AUFA scale to patients hospitalized in the clinical sector of a university hospital in Rio de Janeiro?
To answer the above question, the following objectives were defined: to apply the AUFA scale to patients admitted to the medical clinic; identify and analyze the results of this application, the sociodemographic profile of patients in vogue as well as repercussions on the skin related to the use of sanitary pads and diapers.

METHOD
This is a cross-sectional, descriptive and exploratory observational study carried out at the University Hospital Hospital Universitário Clementino Fraga Filho (HUCFF) of the Universidade Federal do Rio de Janeiro (UFRJ) University.
The method used was observational, with a cross-sectional design, with a time interval for conducting the research being determined, enabling a portrait of the momentary reality 10 .
Araújo FSF, Di Piero KC, Cardinelli CC The descriptive and exploratory character describes characteristics of the population, phenomena, experience reports through observations, records, analyses, classifications and understanding of the acts, without interfering with the analyzed reality, clarifying concepts and ideas 11 .
The study setting was the medical clinic sector of the HUCFF/UFRJ, located in the city of Rio de Janeiro. This sector has 46 beds, divided into 2 wards, one female and one male with the same number of beds.
The participants were patients admitted to the medical clinic unit of that hospital. This study addressed all hospitalized patients during the period of data collection. Thus, there were 46 participants, of both genders and aged 18 years or over, who, during the period of data collection, accepted by free choice to participate in the research and signed the free and informed consent form.
All patients who participated in the study were assured the legal and ethical precepts, based on the approval of the  (Fig. 1).
Complementarily, the MMSE instruments (Fig. 2) and ICIQ-SF (Fig. 3) were used below: The treatment and analysis of the data took place in two parts: the elements from the first phase of the data collection instrument, which consists of the survey participant's general data collection form, were included and analyzed in the Microsoft Excel® 2007 software, giving origin of the identification data of the population.
Comparing the data from the application of the AUFA® Scale, tables were built in Word® to analyze and compare scores and complementary data based on the MMSE and ICIQ-SF.

RESULTS
Of the 46 participants analyzed, 23 (50%) patients were male and 23 (50%) were female. Ages ranged between 40 and 99 years, with higher prevalence in the age group 60 to 69 years. Twenty-one participants (45.65%) declared themselves white and 25 (54.35%) black.
About the level of education, all had incomplete elementary school. As for the reason for admission, all had systemic arterial hypertension, the vast majority being hospitalized for stroke, followed by acute myocardial infarction and dyspnea, as shown in the table below for the characterization of the population studied (Table 1).
When applying the AUFA scale, it was observed that 100% of the participants used diapers, with 28 (60.86%) having no indication for the use of absorbent devices and 18 (39.14%) had a score compatible with the use of diapers or absorbent devices.
Therefore, there was a tendency to use the diaper without prior scientific judgment by nursing, including interference from the decision made by the patient, their family and/or caregiver, who also did not present scientific justification for their use.

19) Ask to copy the design (01 point) /30
Close your eyes ANIMALS ( ) Up to 12 different names ( ) Between 13 and 18 names ( ) More than 18 names    Regarding activities of daily living, 11 (23.91%) patients were classified as independent, 12 (26.09%) partially dependent and 23 (50%), most of them dependent to develop activities of daily living, a situation that determined the need for the presence of a caregiver, interfering positively or negatively in the introduction of the absorbent device and its handling.
Incontinence was assessed using the ICIQ-SF scale and 30 (65.21%) patients were found with absence of incontinence, 12 (26.09%) with mild incontinence and 4 (8.70%) with moderate and severe incontinence, according to table 2, below: The survey data showed that damage to skin integrity did not occur in 19 (41.30%) participants, however more than half had some damage, being 09 (19.56%) grade 1 IAD in areas of genitalia, buttocks, inguinal regions and lower abdomen, and 18 (39.14%) grade 3 IAD.
This fact may also be related to the use of two or more diapers, a situation that is out of line with good health practices, favoring an increased risk for the development of IAD, pressure injury, urinary infection, among others.
IAD is a common clinical manifestation in patients with incontinence. It is a skin inflammation, characterized by edema, erythema and erosive/macerated lesions of the epidermis. [1][2][3]16 due to contact with excretions and moisture, especially in the perineum, genitalia, buttocks, perineal/perianal region, thighs and upper abdomen/adjacencies.
Factors that facilitate or aggravate its installation range from excessive skin moisture, inadequate care in its management, changes in its pH due to the action of excretions and/or use of hygiene products, in addition to the presence of microorganisms and extrinsic factors such as pressure and friction 3,16 .
Therefore, preventive management aims to remove irritating substances from the skin, in addition to gentle handling, combined with the use of protective skin barriers, that is, systematization of nursing care 17 .
Application of the diaper use rating scale in a medical clinic of a university hospital

DISCUSSION
The analysis of the profile of the participants showed the majority of elderly people, with frequency over 60 years of age, a situation that reaffirms the increase in this age group, which, due to the decline of their physiological functions, already determines an increased risk for complications during hospitalization, especially in a medical clinic sector, with diverse demands and different hospitalized patients [18][19][20] .
The aging process determines a reduction in functional capacity, susceptibility to chronic diseases and incontinence.
In addition, there is also the cognitive portion and level of awareness that impact on autonomy and self-care, exacerbating the subject's vulnerability and passivity towards the caregiver 20 .
Regarding the color variable, most participants were black, a situation that raises the importance of early and more detailed skin examinations due to the complexity of identifying initial changes, such as erythema and elementary lesions difficult to be seen on dark skin.
Regarding the level of education, all participants were at elementary level, and knowing that there is a direct relationship between education, quality of life and health, it was observed that low education made it difficult to understand the factors that affect individual health.
The reasons for the current hospitalization of the participants, as well as the common underlying disease among them, are included in the list of non-communicable chronic diseases, with chronic arterial hypertension being prevalent, together with the complications highlighted in the study -stroke and acute myocardial infarction , as well as dyspnea as a symptom that may be related to cardiopulmonary complications.
criteria related to incontinence and the need to use an absorbent device .
In addition, the diagnosis of incontinence should be a priority in the management of these patients with the help of specialists, such as a stomatherapist, to assess the clinical indication, based on technical-scientific precepts, on the real need for the use of absorbent devices.
Thus, avoiding the inadequate implementation of diapers and sanitary pads as a routine of nursing work organization.
Therefore, the practice of nurses needs to be based on theoretical and practical precepts that support decision-making in health and the incorporation of hygiene materials in care. Instruments that systematize the assessment of criteria for the use of diapers in adult patients are essential.
The application of the AUFA scale seems to be an alternative for indicating the use of absorbent devices 6,22 , however, it is necessary to discuss the criteria set out in the scale related to the guidance of the caregiver in the systematization of times for diaper change, specifically every 3 hours, a situation that can determine conflict according to the characteristics of individual incontinence 1,6,22 .
However, without prospective studies evaluating the frequency of diaper change, there is a scientific gap regarding this consensus, a situation that needs to be individualized in relation to intervening variables such as: degree of incontinence, urination volume, skin aspects, pre-existing lesions , mobility, etc.
In addition, each diaper and pad has a degree of absorption and saturation in accordance with the manufacturer's specifications. All of these elements must be taken into account to define the time to change the diaper, so further studies are needed for consensual clinical recommendations.
Thus, broad health education according to good practices in the handling of sanitary pads and diapers based on clinical consensus in health helps institutional policy on quality and patient safety.
Finally, a limitation for this study is the realization of clinical criteria related to diaper use determined by the AUFA scale in a small sample and only one care setting in a university hospital. Despite having addressed the full quantity of patients admitted to the medical clinic during the period of data collection. Above all, the contributions were satisfactory and uncovered a gap in the assistance that must be filled.
Therefore, further studies on the subject are recommended, in addition to cost-effectiveness on the absorbent diaper device related to its clinical application with a greater number of participants, in view of good usage practices. In addition to carrying out the same study in other care scenarios, to assess the AUFA scale with a view to making a decision on diaper indication and handling, including the correct time for changing, with the objective of preventing skin-related complications.

CONCLUSION
It was possible to conclude with this study that there is a need to implement the systematization of nursing care for the indication and management of the use of pads and diapers in adult patients, mostly elderly.
Inappropriate use or without specific indication should negatively impact health conditions, especially on the skin of these patients and on the cost of health care during their hospitalization.
Application of the diaper use rating scale in a medical clinic of a university hospital The systematization of nursing care added to the use of scales to assess and support decision-making, such as the AUFA scale, will guarantee the patient with incontinence and safe and efficient use of pads or diapers, which is a practice based on scientific evidence.
The scientific basis for care is necessary and reinforced by the National Policy on Patient Safety, which outlines axes for the design of safe health care. Actions aimed at prevention, health promotion and safe use of technologies/materials based on technical-scientific concepts support care decisions.
Absorbents and diapers are hygiene materials added to health care, so their use must be justified, requiring protocols aimed at patient safety, especially with analysis of the user profile, facilitated by instruments such as the AUFA scale.
Therefore, this study made it possible to identify that the indication and even management of pads and diapers by nursing is not yet systematized and based on science. Therefore, the use of the AUFA scale proved to be scientifically relevant to guide the individualized analysis of the clientele.

DATA STATEMENT AVAILABILITY
All data were generated or analyzed in this study.