Instruments for wound assessment: scoping review

Authors

DOI:

https://doi.org/10.33448/rsd-v10i11.19246

Keywords:

Wound Healing; Wounds and Injuries; Evidence-based practice.

Abstract

The aim is to identify and describe the main instruments used for wound analysis, in addition to raising their validation and cross-cultural adaptation to the Portuguese language. This is a scope review prepared according to the method proposed by the Joanna Briggs Institute. The Regional Portal of the Virtual Health Library (BVS), MEDLINE (under the Pubmed interface), Scopus, Web of Science, CINAHL, LILACS and Scielo databases were consulted in order to identify studies that used at least one instrument validated for wound assessment by January 2021. Gray literature was verified using Google Scholar. The search strategy was developed using Health Science Descriptors (DeCS) and MeSH terms such as wound healing, assessment study and nursing assessment. Studies were included regardless of the design used, only studies that did not report the use of any instrument for wound assessment, or studies involving preclinical models were excluded. Two reviewers selected the articles independently. The instruments found were described and categorized after the reviewers' calibration. 51 instruments for wound assessment were found in a total of 110 selected studies. These instruments involved different approaches in clinical practice (wound healing, infection, pain caused by the wound, etc.). However, only eight (15.7%) were cross-culturally adapted for use in the Portuguese language. This study suggests that more instruments must be developed and adapted to the Portuguese language of Brazil, so that the diagnosis and treatment of wounds can be more accurate.

Author Biographies

Camila Castanho Cardinelli, Universidade Federal do Rio de Janeiro

Enfermeira líder da Comissão de Métodos Relacionados à Integridade da Pele (COMEIP/Estomaterapia) do HUCFF-UFRJ. Mestranda em Ciência e Tecnologia Farmacêutica - CTECFAR da Faculdade de Farmácia da UFRJ (FF-UFRJ). Especialista em Estomaterapia (UERJ).

Luis Phillipe Nagem Lopes, Universidade Federal do Rio de Janeiro

Aluno de graduação do curso de Farmácia da Universidade Federal do Rio de Janeiro (UFRJ)

Karina Chamma Di Piero, Universidade Federal do Rio de Janeiro

Enfermeira coordenadora da Comissão de Métodos Relacionados à Integridade da Pele (COMEIP) -HUCFF –UFRJ. Doutora em Clínica Médica - Dermatologia (FCM-HUCFF-UFRJ). Especialista em Enfermagem Clínica Médica (MB/UNIRIO), Enfermagem Dermatológica (UGF), Estomaterapia (UERJ) e Qualidade em Saúde e Segurança do Paciente (ENSP/FIOCRUZ).

Zaida Maria Faria de Freitas, Universidade Federal do Rio de Janeiro

Farmacêutica da Farmácia Universitária da UFRJ. Professora quadro permanente, do Programa de Pós-Graduação em Ciência e Tecnologia Farmacêutica - CTECFAR, Faculdade de Farmácia da UFRJ. Departamento de Fármacos e Medicamentos. Doutorado em Fármacos e Medicamentos – Faculdade de Ciências Farmacêuticas – Universidade de São Paulo, USP-SP

References

Abbade, L. P. F. (2010). Preparo do leito da ferida. In W. Malagutti (Ed.), Curativos, Estomias e Dermatologia: uma abordagem profissional. (pp. 63–76). Martinari.

Alves, D. F. dos S., Almeida, A. O. de, Silva, J. L. G., Morais, F. I., Dantas, S. R. P. E., & Alexandre, N. M. C. (2015). Translation and Adaptation of the Bates-Jensen Wound Assessment Tool for the Brazilian culture. Texto Contexto Enferm, 24(3), 826–833. https://doi.org/10.1590/0104-07072015001990014

Aron, S., & Gamba, M. A. (2009). Preparo do Leito da Ferida e a História do TIMEWound Bed Preparation and a History of TIME. ESTIMA, Braz. J. Enterostomal Ther., 7(4).

Bates-Jensen, B. M., Vredevoe, D. L., & Brecht, M. L. (1992). Validity and reliabitity of the Pressure Sore Status Tool. Decubitus, 5(6), 20–28.

Bergin, S. M., Gurr, J. M., Allard, B. P., Holland, E. L., Horsley, M. W., Kamp, M. C., Lazzarini, P. A., Nube, V. L., Sinha, A. K., Warnock, J. T., Alford, J. B., & Wraight, P. R. (2012). Australian Diabetes Foot Network: management of diabetes‐related foot ulceration — a clinical update. Medical Journal of Australia, 197(4), 226–229. https://doi.org/10.5694/mja11.10347

Brasil. (2021). Sistema de Informações sobre Mortalidade - SIM. http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sim/cnv/obt10RJ.def

Cardinelli, C. C., Lopes, L. P. N., Di Piero, K. C., & Freitas, Z. M. F. (2021). Tools for wound assessment: a scoping review. https://doi.org/ 10.17605/OSF.IO/SREY3

Carville, K., Lewin, G., Newall, N., Haslehurst, P., Michael, R., Santamaria, N., & Roberts, P. (2007). STAR: a consensus for skin tear classification. Primary Intention, 15(1), 8–25.

Chadwick, P., Edmonds, M., McCardle, J., & Armstrong, D. (2013). International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers. Wounds International.

Costa, R. K. de S., Torres, G. de V., Salvetti, M. de G., Azevedo, I. C. de, & Costa, M. A. T. da. (2015). Instrument for evaluating care given by undergraduate nursing students to people with wounds. Revista Da Escola de Enfermagem Da USP, 49(2), 0317–0325. https://doi.org/10.1590/S0080-623420150000200018

Dantas, D. V., Torres, G. D. V., & Dantas, R. A. N. (2012). Assistência aos portadores de feridas: caracterização dos protocolos existentes no Brasil. Ciência, Cuidado e Saúde, 10(2). https://doi.org/10.4025/cienccuidsaude.v10i2.8572

Domingues, E. A. R., Carvalho, M. R. F., & Kaizer, U. A. de O. (2018). Adaptação transcultural de um instrumento de avaliação de feridas. Cogitare Enfermagem, 23(3), e2684. https://doi.org/10.5380/ce.v23i3.54927

EPUAP, NPIAP, & PPPIA. (2019). Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline (3a). EPUAP/NPIAP/PPPIA.

Evans, R., Kuhnke, J. L., Burrows, C., Kayssi, A., Labrecque, C., O’Sullivan-Drombolis, D., & Houghton, P. (2019). Best Practice Recommendations For The Prevention and Management of Venous Leg Ulcers. Canadian Association of Wound Care (Wounds Canada).

Garbuio, D. C., Zamarioli, C. M., Silva, N. C. M. da, Oliveira-Kumakura, A. R. D. S., & Carvalho, E. C. (2018). Instrumentos para avaliação da cicatrização de lesões de pele: revisão integrativa. Rev. Eletr. Enferm, 20. https://doi.org/10.5216/ree.v20.49425

Günes, U. Y. (2009). A prospective study evaluating the Pressure Ulcer Scale for Healing (PUSH Tool) to assess stage II, stage III, and stage IV pressure ulcers. Ostomy Wound Manage, 55(5), 48–52.

Harris, C., Bates-Jensen, B., Parslow, N., Raizman, R., Singh, M., & Ketchen, R. (2010). Bates-Jensen Wound Assessment Tool. Journal of Wound, Ostomy & Continence Nursing, 37(3), 253–259. https://doi.org/10.1097/WON.0b013e3181d73aab

Healey, F. (1997). Classificação das úlceras de pressão II. Nursing, 109, 16–20.

International Diabetes Federation. (2015). IDF Diabetes Atlas (7a.).

Leblanc, K., Baranoski, S., Christensen, D., Langemo, D., Sammon, M. A., Edwards, K., Holloway, S., Gloeckner, M., Williams, A., Sibbald, R. G., & Regan, M. (2013). International skin tear advisory panel: A tool kit to aid in the prevention, assessment, and treatment of skin tears using a simplified classification system. Advances in Skin and Wound Care, 26(10), 459–476. https://doi.org/10.1097/01.ASW.0000434056.04071.68

Lima, R. V. K. S., Coltro, P. S., & Farina Júnior, J. A. (2017). Negative pressure therapy for the treatment of complex wounds. Revista Do Colégio Brasileiro de Cirurgiões, 44(1), 81–93. https://doi.org/10.1590/0100-69912017001001

Lipsky, B. A., Berendt, A. R., Cornia, P. B., Pile, J. C., Peters, E. J. G., Armstrong, D. G., Deery, H. G., Embil, J. M., Joseph, W. S., Karchmer, A. W., Pinzur, M. S., & Senneville, E. (2012). 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infectionsa. Clinical Infectious Diseases, 54(12), e132–e173. https://doi.org/10.1093/cid/cis346

Mandelbaum, S. H., Di Santis, É. P., & Mandelbaum, M. H. S. (2003). Cicatrização: conceitos atuais e recursos auxiliares - Parte I. An. Bras. Dermatol., 78(4), 393–408. https://doi.org/10.1590/S0365-05962003000400002

Olczyk, P., Mencner, Ł., & Komosinska-Vassev, K. (2014). The Role of the Extracellular Matrix Components in Cutaneous Wound Healing. BioMed Research International, 2014, 1–8. https://doi.org/10.1155/2014/747584

Ousey, K., Rogers, A. A., & Rippon, M. G. (2016). Hydro-responsive wound dressings simplify T.I.M.E. wound management framework. British Journal of Community Nursing, 21(Sup12), S39–S49. https://doi.org/10.12968/bjcn.2016.21.Sup12.S39

Peters, M., Godfrey, C., McInerney, P., Munn, Z., Trico, A., & Khalil, H. (2020). Chapter 11: Scoping Reviews. In JBI Manual for Evidence Synthesis. JBI. https://doi.org/10.46658/JBIMES-20-12

Restrepo-Medrano, J. C., & Verdú Soriano, J. (2011). Desarrollo de un índice de medida de la evolución hacia la cicatrización de las heridas crónicas. Gerokomos, 22(4), 176–183. https://doi.org/10.4321/S1134-928X2011000400005

Santos, V. L. C. de G., Azevedo, M. A. J., Silva, T. S. da, Carvalho, V. M. J., & Carvalho, V. F. de. (2005). Adaptação Transcultural Do Pressure Ulcer Scale For Healing (Push) Para A Língua Portuguesa. Rev Latino-Am Enfermagem, 13(3), 305–313.

Silva, C. V. B., Campanili, T., LeBlanc, K., Baranoski, S., & Santos, V. (2018). Adaptação cultural e validade de conteúdo do ISTAP Skin Tear Classification para o português no Brasil. ESTIMA, Braz. J. Enterostomal Ther, 16, e2618. https://doi.org/10.30886/estima.v16.590_PT

Silveira, I. A., Oliveira, B. G. R. B. de, Souza, P. A. de, Santana, R. F., & Carvalho, M. R. de. (2020). Cross-cultural adaptation of the Leg Ulcer Measurement Tool for Brazil: nursing methodology research. Revista Brasileira de Enfermagem, 73(4). https://doi.org/10.1590/0034-7167-2018-0944

Strazzieri-Pulido, K. C., Santos, V. L. C. de G., & Carville, K. (2015). Cultural adaptation, content validity and inter-rater reliability of the “STAR Skin Tear Classification System.” Revista Latino-Americana de Enfermagem, 23(1), 155–161. https://doi.org/10.1590/0104-1169.3523.2537

Tchero, H., Kangambega, P., Fluieraru, S., Bekara, F., & Teot, L. (2019). Management of infected diabetic wound: a scoping review of guidelines. F1000Research, 8, 737. https://doi.org/10.12688/f1000research.18978.1

Tricco, A. C., Lillie, E., Zarin, W., O’Brien, K. K., Colquhoun, H., Levac, D., Moher, D., Peters, M. D. J., Horsley, T., Weeks, L., Hempel, S., Akl, E. A., Chang, C., McGowan, J., Stewart, L., Hartling, L., Aldcroft, A., Wilson, M. G., Garritty, C., & Straus, S. E. (2018). PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Annals of Internal Medicine, 169(7), 467–473. https://doi.org/10.7326/M18-0850

Waidman, M. A. P., Rocha, S. C., Correa, J. L., Brischiliari, A., & Marcon, S. S. (2011). O Cotidiano Do Indivíduo Com Ferida Crônica E Sua Saúde Mental. Texto Contexto Enferm2, 20(4), 691–699.

Woodbury, M. G., Houghton, P. E., Campbell, K. E., & Keast, D. H. (2004). Development, validity, reliability, and responsiveness of a new leg ulcer measurement tool. Adv Skin Wound Care, 17(4), 187–196. https://www.ncbi.nlm.nih.gov/%0Apubmed/15360028

Yamada, B. F. A., & Santos, V. L. C. de G. (2009). Development and Validation of Ferrans & Powers Quality of Life Index - Wound version*. Rev Esc Enferm USP, 43(Spe), 1033–11.

Published

25/08/2021

How to Cite

CARDINELLI, C. C. .; LOPES, L. P. N. .; DI PIERO, K. C. .; FREITAS, Z. M. F. de . Instruments for wound assessment: scoping review. Research, Society and Development, [S. l.], v. 10, n. 11, p. e144101119246, 2021. DOI: 10.33448/rsd-v10i11.19246. Disponível em: https://rsdjournal.org/index.php/rsd/article/view/19246. Acesso em: 18 dec. 2024.

Issue

Section

Review Article