Instruments to Assess the Subjective Repercussions of People with Chronic Wounds : Integrative Review

Objective: To analyze the instruments described in the literature for extended assessment in people with chronic wound. Materials and methods: Study of integrative review of the literature. The search was conducted on databases including PUBMED, Web of Science, SciELO, CINAHL, Science Direct (Elsevier), Scopus, and Biblioteca Virtual da Saúde (BVS). Results: The search found 19 060 articles; after relevance tests, 41 were left. The instrument most used in the studies of this review was the Short Form 36 Health Survery (SF-36), which is a tool to assess quality of life (QOL). Conclusion: A diversity of instruments was identified for extended assessment of people with wounds, with those investigating QOL being the most frequent. The repercussions are, mostly, contained in the QOL assessment instru-


Introduction
The occurrence of chronic wound, to the demands and limitations caused by the ulcer, triggers several representations to individuals.In this sense, it is possible that the following situations are observed: Chronic pain syndrome, change in body image, reduced work capacity, and altered family and social dynamics.They can lead individuals to a condition of social isolation, which impacts upon their quality of life (QOL) (1,2).
To adequately care for these individuals, technical-scientific knowledge is necessary that considers aspects that go beyond the topical care of lesions.It is necessary to address the impacts of wounds on the daily lives of individuals, respecting the feelings, sensations, and biopsychosocial needs that must be addressed (3).
To be resolute in the context of clinical practice, interventions in the aforementioned situations must be systematized and based on scientific evidence, so that cases are duly followed up.In this sense, strategies exist to aid professionals to minimize the bias of subjectivity associated with this type of evaluation.
It is known that to make a holistic approach in people with chronic comorbidities, it is necessary to consider the aspects mentioned.Nevertheless, identifying those conditions may not be a simple task, given that these are aspects involving personal interpretations or impressions.This makes the evaluations made by the professionals superficial, detailed, or very subjective.
An important tool to guide said assessment is the use of Patient Report Outcome Measures (PROM), which are instruments that permit knowing and measuring patients' opinions about their health and which, when applied during different moments of treatment, enable monitoring possible changes.These instruments serve as an aid because they estimate the evaluation in measurable manner and favor follow-up without the evaluator's personal impressions (4).
Currently, several instruments are available for said purpose in diverse populations, even in people with wounds.However, it is observed that each study chooses a method, based on its priorities, and indicates somewhat inconclusive results regarding the use of the method chosen.Knowing the instruments that evaluate beyond the conditions of healing can contribute to the integral care of the individual, as well as influence upon decisions of care, treatment and/or interventions, along with the formulation of health programs and institutional policies (5).
Thus, this research is justified by the need to identify which of these instruments are or are not validated and to evidence their particularities.The initiative can favor the actions of professionals caring for people with those characteristics, with the purpose of optimizing the evaluation of psychophysiological repercussions.
By identifying the most effective instruments, it is possible to plan more assertive interventions in clinical practice and conduct experimental research, as well as aid in the professional formation of nurses and other professionals caring for said patients.

Objective
To analyze instruments of subjective evaluation of people with chronic wound described in the literature.

Materials and methods
This was a study of integrative review of the literature, conducted from August 2016 to July 2017.For the purpose of reporting this study, the work followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).This is a checklist with 27 items, seeking to help authors to direct, more consistently and objectively, the presentation of systematic reviews and meta-analyses (6).
To elaborate the research question, the PVO strategy was used, where (P) is the person with chronic wound, (V) are the evaluation instruments, and (O) the outcomes the individual presents (6).The guiding question of this study was: What instruments are used for a subjective evaluation in people with chronic wounds?
The research included articles written between February 2006 and February 2017; in Portuguese, English, and Spanish; articles dealing with extended evaluation in people with chronic wounds (pressure lesions and/or leg ulcer, patients with complications in the feet due to diabetes mellitus, psoriasis), and also articles that use instruments for this evaluation.Dissertations, theses, book chapters, editorials, reviews, comments, abstracts, systematic and integrative review articles, and duplicate articles were excluded.
On 16 February 2017, a search was conducted in the following databases: National Library of Medicine (Medicine - PUBMED), Web of Science, Electronic Library Online (SciELO), Cumulative Index of Nursing and Allied Health Literature (CI-NAHL), Science Direct (Elsevier), Science Direct (Scopus), and Biblioteca Virtual em Saúde (BVS).The following search strategy was used: "quality of life" OR "fatigue" OR "pain" OR "anxiety" OR "depression" AND "wounds and injures" OR "leg ulcer" OR "varicose ulcer" OR "pressure ulcer" OR "diabetic foot" AND "evaluation" OR "evaluation of research programs and tools".
The 19 060 articles identified in the search were saved, on the same day via E-mail, to control and apply relevance tests (RT) elaborated according to the inclusion criteria, which were established from the research question (7).The study considered articles in English, Portuguese, and Spanish, published between 2006 and 2017, and which addressed leg ulcer or holistic subjective assessment of the individual.First, the RT was applied to the titles of the articles identified, configuring RT 1, and, thereafter, the abstracts, representing the RT 2. Thus, duplicates, theses, dissertations, monographs, book chapters, editorials, opinion articles, and literature reviews were also excluded.
A form was drawn up to extract data from each article.Thus, extraction, organization, and summarization of information continued through the analysis of authenticity, methodological quality, importance of information, and representativeness, as well as the judgment of the study with regard to the degree of evidence (7,8).To verify the degree of evidence of each article selected, the study used the Joanna Briggs reviewer's manual, elaborated as a comprehensive guide to conduct systematic reviews, by categorizing the studies from their methodological designs (8).

Results
From the search in all the databases, 19 060 articles were obtained; by applying the relevance test 1, 18 726 were excluded because of language, temporal cut prior to 2006, and not addressing repercussions among people with chronic wounds.Thereafter the relevance test 2 was applied, which excluded 293 articles because they did not contain instruments of extended assessment, and being duplicates and literature review articles, theses, dissertations, opinion articles, course completion works, and editorials.Thus, 41 articles were included to read in full and extract data (Figure 1).Table 1 evidences the characterization of the 41 studies selected, according to methodological design, population, objective, conclusion, and level of evidence, according to recommendations by the Joanna Briggs Institute (8).
A higher number of publications was identified after 2014, indicating a growing demand for greater understanding on aspects concerning the extended assessment of people with chronic wounds.
In relation to the characteristics of the populations studied, 31 studies (75.6 %) had prevalence of female gender; in 63.4 % of the studies, age ranged between 60 and 70 years.The comorbidities found were diabetes (39 %), vascular disease (26.8 %), diabetes and  In all the domains of the Diabetic Foot Scale (DFS), QOL was improved over the cohort of our patients (p ˂ 0.0001), independent of their outcome (healing or amputation).Significant improvement was also observed in self-care after follow up.The study did not evidence significant difference in QOL among patients with chronic neuropathy with and without foot ulcer, due to complications of DM, except for the subscale bodily pain, which had lower scores in patients who did not have ulcer (p: 0.04).The CCVUQ-e has good internal consistency (Cronbach's alpha ≥ 0.80).The correlation between the CCVUQ-e and the PUSH-e, at the beginning of the search, was r: 0.49 (p: ≤ 0.001), and, after six weeks it was r: 0.64 (p: 0.006).The instruments demonstrated adequate sensitivity to change (p: ≤ 0.001).Hence, the preliminary results show that the CCVUQ-e has satisfactory psychometric properties.In terms of the etiology of the lesion, there was significant relevance of the studies of people with leg ulcers (LU) (92.7 %), followed by pressure lesion (7.3 %).Studies with LU identified those that evaluated different populations, of which 16 (42.2%) addressed people with foot ulcers due to complications of diabetes mellitus (DM), 16 (42.%) venous ulcer, two (5.2 %) arterial ulcer, one (2.6 %) neuropathic ulcer, one (2.6 %) compared populations with venous ulcer and ulcer due to complication of DM, one (2.6 %) compared people with ulcers due to psoriasis and leg ulcer, and one (2.6 %) compared populations with and without foot ulcers due to complications of DM.
Table 2 describes the assessment instruments used in the investigations.Of these, 15 (36.5 %) studies opted for using more than one instrument to evaluate the human repercussions investigated, or even evaluated more than one repercussion in the same study.
Considering the studies (n = 35, 85.3 %) that evaluated QOL, concomitantly, three studies (8.5 %) evaluated bio-physiological dimensions, sought correlations with QOL.Of these, one (33.3%) evaluated the healing conditions through the Pressure Ulcer Scale Healing (PUSH); one (33.3%), mental state through the Mental State Mini Exam; and one (33.3%), the functional capacity of the ankle through the Foot Ankle Ability Measurement.In turn, 11 (31.4 %) studies evaluated QOL simultaneously with another psycho-physiological or psychosocial repercussion, with emphasis for "pain" (45.4 %) as repercussion most associated in the studies.The studies of said review (11,14,20,21,22,38,39) evidenced that greater pain meant lower QOL of patients with leg ulcers and pressure lesion.
Thirty-three instruments were identified in the studies of this review, with 18 (54.5 %) being referents to assess QOL.Among them, we highlight the Short Form 36 Health Survey (SF-36), identified in eight (44.4 %) studies, and the Charing Cross Venous Ulcer Questionnaire (CCVUQe), used in six (33.3 %).It should be emphasized that of the studies evaluating QOL, five (14.2 %) use more than one instrument to evaluate that same repercussion.Of these, one (20.0%) study used four different instruments, and, in the rest (80.0 %) investigated, two instruments were identified.
Regarding the dimensions evaluated in the QOL instruments (n = 18), higher occurrence was observed of the referents to activities of daily life, identified in 13 (72.2%) instruments.Questions corresponding to the evaluation of the dimension of "pain and discomfort" were found in nine (50 %) instruments, as well as "social aspects" in eight (44.4 %) and "emotional aspects" in six (33.3 %).It should also be noted that the same instrument contains an evaluation of more than one of the dimensions mentioned.Some instruments, like the Venous Leg Ulcer QOL (VLU-QOL) guide the research considering the clinical characteristics according to the etiology of the ulcers, through most commonly observed symptoms.
In relation to the other repercussions, four instruments identified were used, each, in four (12.1 %) studies: Diabetic Foot Ulcer Scale (DFS), Visual Analog Scale (VAS), Rosenberg Selfesteem Scale, and Hospital Anxiety and Depression Scale (HADS).The instruments Health Survey (SF-12) and Beck's depression and anxiety inventory were identified in three (9.1 %) studies each.Lastly, the Dermatology Quality Index (DLQI), EQ-5D Powerlessness Assessment Tool (PAT) questionnaire, and Loneliness scale (UCLA) were each used in two (6.1 %) studies.Composed by 35 items distributed into six domains: Pain, reduction of sensitivity, diffuse sensory-motor symptoms, limitations of activities in daily life, disorder in social relationships, and emotional anguish.There are also two final items on the scale that assess, respectively, the impact of foot changes on QOL and on its overall classification.The scores are calculated by the average of the weighted items of domains.The score varies between 1 and 15 in which higher values indicate worse QOL.Seeks to provide qualitative measurements of pain that can be analyzed statistically.Evaluates the sensory, affective, temporal and miscellaneous qualities of pain.In addition, it presents an evaluation of the spatial distribution and intensity of pain ("without pain" to "excruciating").

Self-esteem
Rosenberg Self-Esteem Scale (RSES) 4 9.7 % E4, E9, E18, E21 Adult patients RSES is a 10-item questionnaire answered in a 4-point scale.Scores vary from 0 to 30; scores from 15 to 25 are considered within the normal interval, while scores below 15 suggest feelings of low self-esteem.
The Body Investment scale* 1 2.4 % E21 Adult patients Includes 20 items grouped into four domains: Bodily feelings, body touch, bodily care, and bodily protection.The items are scored in a 5-point Likert scale, varying from totally disagree (1) to totally agree (5).

Anxiety and depression
Hospital Anxiety and Depression Scale (HADS)* 4 9.7 % E4, E18, E37, E41 Adults in diverse clinical situations HADS has 14 items, projected to measure anxiety and depression, most likely to cause psychological suffering in patients (seven items for each subscale).Answers to the items are indicated in a 4-point Likert scale from 0 to 3, with a high score indicating more symptoms.

Adults in postoperatory
The instrument consists of a measure of 12 items distributed into three domains: Capacity to perform behavior, perception of the capacity to make decisions, and emotional response to the control of situations.The PAT evaluates the feeling of powerlessness in a 5-point Likert-type scale, varying from "never" (1) to "always" (5).The total PAT varies between 12 and 60, with higher scores corresponding to strong feeling of powerlessness.Evaluates three aspects of healing: Size of the ulcer, amount of exudate and type of tissue.Each has a sub-score that will be added and will form the total score.The lower the score, the better the prognosis.

Adults in diverse clinical situations
Developed as a specific measure to verify the functionality of people with muscular-skeletal disorders of the ankle-foot complex.It evaluates two aspects: Activity of daily life (ADL) and sports appraisals.The ADL subscale includes 21 activities, and the sports subscale includes eight activities.Patients are asked to register the difficulty the face with various activities.There are three scores, one for each subscale and a total score.The maximum score in the ADL and sports subscale is 84 and 32, respectively.

General health
The Short Form Global Health of PROMIS 1 2.4 % E27 Patients with chronic disease Composed of 10 items that evaluate aspects of physical, mental, and social health, plus an item to classify general health.This instrument is composed of two specific scales, Global Physical Health and Global Mental Health, each composed of four items.The Global Physical Health scale includes items of physical health (03), physical function (06), intensity of pain (07), and fatigue (08).And the scale of Global Mental Health is constituted by items of QOL (02), mental health (04), satisfaction with social activities and relationships (05), and emotional problems (Global 10).The answer categories are Likert-type scales of 5 points, except for the Global 07 item, which evaluated by a scale from 0 to 10 in which 0 means lack of pain and 10 presence of worse pain imaginable.

Discussion
Regarding the design diversity of the studies included, it is associated with the research question of this review that sought to know the instruments introduced in the literature for extended assessment of people with wounds.As expected, studies related to psychometrics were identified, however, it is possible to observe the scarcity of clinical research in this assessment context, making it difficult to judge the applicability of the instruments.
The greater occurrence of research carried out in American countries, especially Brazil, reinforces the potential to conduct investigations on this theme.Nursing still needs further investment to carry out studies like these, given that it is one of the professional areas with greatest contact with the studied population, and which, sometimes, identifies nuances of the multidimensional repercussions among these individuals in the daily care.In addition, research is a recommended assessment demand in specific guidelines to approach this population (2).
In relation to the characteristics of the population found in the articles in this review, the results reinforce the findings from the literature for the etiologies identified (50).This fact points to the presence of specific profiles that may help in directing actions in the context studied.
It is possible to identify association between sociodemographic data and psychosocial repercussions, like the highest occurrence of low self-esteem, anxiety, and depression in women, which can be related to a higher number of stressful factors, such as pregnancy, menopause, and social oppression (51,52).Another example is the occurrence of depression associated to age, demonstrated by changing roles and, consequently, by alterations resulting from interaction and social function, in addition to continuous use of many medications (53,54).
The prevalence of studies that address people with leg ulcers can be associated to the profile of the individuals in what refers to socioeconomic aspects.Because of their lower morbidity in relation to individuals with pressure lesion, leg ulcer patients still perform functions in the groups and social institutions to which they belong; people with pressure lesion, due to the most frequent comorbidities, like cancer and neurological disorders (45,46), are unable to perform these roles.In this sense, it may be inferred that instruments specific to the etiology of the lesions can guide the approach and identify more precisely the broader repercussions, without ignoring the need to validate this affirmation in different clinical and cultural contexts.
The diversity of instruments existing in the literature to assess the human repercussions mentioned points to understanding the complexity of the investigation, as well as for the possibility of these instruments meeting different objectives, considering variables, like clinical practice, teaching, and research, which needs validation by other studies.
Evaluation of QOL, as the most frequent outcome investigated in the instruments found, draws attention to the scope of the theme and points to the possibility of exhausting the subjective assessment (holistic) of these individuals.However, it should be emphasized that the approach, in some instruments of QOL, is superficial or even inconsiderate in relation to certain repercussions, such as "feeling of powerlessness", "anxiety", "depression", and "social aspects" (22,41,47).Said finding indicates that QOL instruments can be tracers and not determinants in judging the presence or absence of these repercussions in this population.
Pain was also investigated frequently in the instruments, being an important aspect in the multidimensional evaluation of professionals in this type of care, despite being detailed or inadequately addressed.Assessment of pain, if carried out regularly, allows nurses to become aware of the level of pain manifested by patients not only when conducting certain procedures.Additionally, the frequency of evaluation will enable obtaining information related to the intensity of pain that people with venous ulcers must endure or experience in their daily lives.Thus, it may be stated that the evaluation and registry of intensity of pain permit patients greater possibility of control over their condition, with positive effect on their capacity to develop strategies to cope with the problem.Assessment of pain is also a means of measuring the efficacy and response to treatment, and influences the prognosis (19,22,28,29,30,46,47).Pain represents an infectious process, neuropathy (22), or even psycho-emotional aspects involved (22,28,29).Through several instruments validated to evaluate the intensity and characteristic of pain, it is recommended to use the same instrument to facilitate comparison of results and evolution of cases.Such instruments can be determinant in the selection or adjustments in doses of analgesics, as well as in prescribing the most adequate coverage for healing (55).
This study highlights the visual analogue scale of pain and the questionnaire on pain by de McGill as instruments to evaluate and measure pain in patients with wounds.Although specific instruments exist to aid in this evaluation, they are still poorly used in clinical practice.In a study conducted in Brazil, in four hospitals that had the so-called "curative commissions", merely 5 % of the nurses used some specific instrument to assess pain (56).This fact points to the need for a review of managerial aspects and to greater understanding by professionals regarding the importance of this evaluation.
The greater occurrence of the use of the SF-36 can be justified because it is an instrument that addresses a greater diversity of the dimensions identified as human repercussions, besides comparing the current perception of health in different temporal cut-offs (57), or in clinical situations and different care scenarios (58).While promoting a wide-ranging assessment of various dimensions, this type of instrument does not address major repercussions that affect the chronic wound, such as self-esteem, anxiety, depression, feelings of powerlessness, and loneliness.
A search made with people with chronic wounds identified that the perception of those with chronic lesion is marked by pain, preconception, dependence for daily activities, and consequential emotional alterations.Patients face the adversities resulting from the lesion in different ways, and health professionals, especially nurses, must respect the individuality and understand how those repercussions affect patients (1).
In Nursing, theoretical references can help direct the holistic approach to this population, besides supporting the systematization of actions.The theory by Wanda de Aguiar Horta, "Theory of Basic Human Needs", represents simple possibilities applicable in various contexts of clinical practice (59), and which can be jointly implemented in the evaluation of subjective repercussions of this population.Thus, the importance is evident of directed evaluation by the nurse to implement and use certain instruments, considering the social and clinical context of the population with wounds to be cared for.

Conclusion
Diverse instruments were identified for extended assessment of people with wounds, with those investigating QOL being the most frequent.The other subjective repercussions found in the instruments analyzed were: Anxiety, depression, loneliness, self-esteem, feelings of powerlessness, and perceived social support, in addition to specific instruments to evaluate mental state and healing.
The repercussions are, mostly, contained in instruments to evaluate QOL, but superficially and/or not very explicit, like in the SF-36, an instrument identified most frequently in the studies of this review.Hence, it is therein inferred that QOL instruments can be considered trackers of alterations of the aforementioned repercussions, but they hinder more directed judgment.
The findings in this research reinforce the contributions of using instruments for extended assessment of people with chronic wounds, and suggest the possibility of differentiated implications, according to the etiology of the lesions, psychosocial and psychospiritual needs of the individual, as well as the context to which they are destined, that is, teaching, clinical practice, or research.
It is also worth highlighting the importance of further studies that can validate the use of evaluation instruments in the various scenarios to indicate their evidence in a directed and, consequently, safer manner.

Figure 1 .
Figure 1.Flowchart of the study inclusion process Evaluate the influence of pain on QOL of patients with foot ulcer due to complication of DM.The ulcer affects significantly the QOL of the patient.Patients who had pain with greater frequency evidence lower QOL.A statistically negative correlation was found among the intensity of pain and QOL in the following domains: Physical health (r = 0.592; p < 0.001), daily activities (r = 0.456; p < 0.001), emotions (r = 0.503; p < 0.001), and treatment (r = 0.434, p < Validate the Spanish version of the Charing Cross Venous Ulcer Questionnaire (CCVUQ-e).

Table 1 .
Characterization of the studies according to type, population, objective, conclusion, and level of evidence.Goiania, 2017.
Diabetic patients with foot ulcers had varying degrees of depressive symptoms, with prevalence of "moderate" level (64 %) and symptoms: Self-depreciation, sadness, and distortion of the bodily image.The statistical difference between the levels "Minimum or none" and "Moderate", with relation to number of depressive symptoms, was significant (p < 0.001).

Table 2 .
Human impacts and respective instruments of extended assessment applied among people with chronic wounds.Goiania, 2017 DLQI has 10 items divided into four domains: Personal relationships, daily activities, leisure, and treatment.The maximum score is 30, with 0 indicating the lower damage and 30 the greater commitment in the patient's QOL.
Physical symptoms, daily life, social life, psychological wellbeing, treatment, and satisfaction.The calculation of the domains is carried out by the arithmetic mean of each response, after recoding the satisfaction domain.The total score is through the mean values of the domains.Consists of 26 items: 10 related to symptoms, nine to performance of activities of daily life, one to the time of day that the symptoms are more intense, one to changes occurring in relation to the disease in the last year, and five to the psychological impact.The time considered for questions related to symptoms, limitations in daily life, and psychological impact comprises the last four weeks.QOL contains 10 domains: Pain, exudate, smell, sleep, mobility, activity, vitality, emotional, wellbeing, and self-concept.Patients assess "nuisance" level assigned over the past week on a 3-point response scale.The scores of the scale are generated by the sum of items, with lower scores indicating better result.includes 29 statements on the potential effects of the dermatological condition, divided into eight domains: Cognitive effects, social effects, effects of the depression, fear, shame, anger, discomfort, and limitations.The score varies between 29, corresponding to the highest QOL or lack of negative effects of the condition, and 145, corresponding to lower QOL or maximum negative influence of the condition.
Composed of 17 items, with three domains: Daily life, bodily, and psychological.Patients are asked how many times they felt any of the 17 items and they respond (not even a little, a little, moderately, very much, extremely).
restless, and suicidal thoughts.And presents a tenth question that evaluates the impact of these symptoms in activities of daily life.Each item is considered positive if it remains for more than half the days in the last two weeks.
Family, friends, and significant others.Likert-type scale in which the lowest score is 12 and the highest is 28, with the higher scores indicating higher level of social support.