1 Joyce Souza Lemes1 Kelle Vanessa Álvares Amaral2 Cynthia de Assis Barros Nunes3 Ana Clara Alves Campo4 Alexia Nunes Batista5 Suelen Gomes Malaquias6 Instruments to Assess the Subjective Repercussions of People with Chronic Wounds: Integrative Review 1 orcid.org/0000-0002-7401-2608. Faculdade de Enfermagem, Universidade Federal de Goiás, Brazil. joyce@enf.grad.ufg.br 2 orcid.org/0000-0002-9758-4270. Faculdade de Enfermagem, Universidade Federal de Goiás, Brazil. kelle.amaral@ebserh.gov.br 3 orcid.org/0000-0001-8322-8737. Faculdade de Enfermagem, Universidade Federal de Goiás, Brazil. chyntia@posgrad.ufg.br 4 orcid.org/0000-0002-1683-7249. Faculdade de Enfermagem, Universidade Federal de Goiás, Brazil. anaclara@enf.grad.ufg.br 5 orcid.org/0000-0002-0031-4400. Faculdade de Enfermagem, Universidade Federal de Goiás, Brazil. alexianb@enf.grad.ufg.br 6 orcid.org/0000-0001-8530-9100. Faculdade de Enfermagem, Universidade Federal de Goiás, Brazil. suelen.g.malaquias@ufg.br Received: 28/07/2018 Sent to peer reviewers: 22/08/2018 Accepted by peers: 28/10/2018 Approved submission: 29/11/2018 DOI: 10.5294/aqui.2019.19.1.8 To reference this article / Para citar este artículo / Para citar este artigo Lemes JS, Amaral KVA, Nunes CAB, Campos ACA, Batista AN, Malaquias SG. Instruments to Assess the Subjective Repercussions of People with Chronic Wounds: Integrative Review. Aquichan 2019; 19(1): e1918. DOI: 10.5294/aqui.2019.19.1.8 ABSTRACT 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- AÑO 19 - VOL. 19 Nº 1 - CHÍA, COLOMBIA - FEBRERO 2019 l e1918 Theme: Evidence-based practice. Contribution to the discipline: This review sought to contribute to better understanding of the instruments of subjective or ho- listic assessment of individuals with chronic wounds. It is necessary for nursing care to consider the individual as a whole, which can be facilitated from the theoretical reference by Wanda de Aguiar Horta through the theory of Basic Human Needs. Hence, the selection of instruments capable of assessing the broader needs of a population, enables the systematization of nursing care and the orientation towards more assertive interventions. Instruments that evaluate quality of life are capable of evaluating people with wounds, suggesting that other repercussions are identified through said evaluation. It is highlighted that evidence-based practice (EBP) emerges from the clinical observations and from the essential demands, which provides health professionals knowl- edge, in systematic and consistent manner, to support their decision-making on health care to individuals. Thus, within the context of this study, evidence-based actions minimize intuitive behaviors and aid in the systematization of nursing care. http://orcid.org/0000-0002-7401-2608 http://orcid.org/0000-0002-9758-4270 http://orcid.org/0000-0001-8322-8737 http://orcid.org/0000-0002-1683-7249 http://orcid.org/0000-0002-0031-4400 http://orcid.org/0000-0001-8530-9100 http://dx.doi.org/10.5294/aqui.2019.19.1.8 http://orcid.org/0000-0002-8810-9937 http://orcid.org/0000-0002-9758-4270 http://orcid.org/0000-0001-8322-8737 https://orcid.org/0000-0002-1683-7249 https://orcid.org/0000-0002-0031-4400 https://orcid.org/0000-0002-0031-4400 http://dx.doi.org/10.5294/aqui.2019.19.1.8 2 AQUICHAN - ISSN 1657-5997 - eISSN 2027-5374 AÑO 19 - VOL. 19 Nº 1 - CHÍA, COLOMBIA - FEBRERO 2019 l e1918 ments, but superficially and/or not explicitly, as in the SF-36, the means most-frequently identified in the studies of this review. These findings suggest the likelihood of differentiated implications of these instruments according to the etiology of the lesions, psychosocial and psychospiritual needs of the individual, as well as the context to which they are destined, like teaching, clinical practice, or research. KEYWORDS (source: Decs) Quality of life; wounds and injuries; leg ulcer; evaluation; evaluation of research programs and tools. Instrumentos para evaluar las repercusiones subjetivas de personas con heridas crónicas: revisión integrativa RESUMEN Objetivo: analizar los instrumentos descritos en la literatura para evaluación ampliada en personas con herida crónica. Material y métodos: estudio de revisión integrativa de la literatura. La investigación se realizó en las bases de datos PUBMED, Web of Science, SciElo, CINAHL, Science Direct (Elsevier), Scopus y Biblioteca Virtual de la Salud (BVS). Resultados: se encontraron 19 060 artículos; después de las pruebas de relevancia, quedaron 41. El instrumento más utilizado en los estudios de esta revisión fue el Short Form 36 Health Survery (SF-36), que es una herramienta de evaluación de la calidad de vida (CV). Conclusión: se identificaronó diversidad de instrumentos para evaluación ampliada de personas con heridas, siendo los de investigación de la CV los más frecuentes. Las repercusio- nes están, en su mayoría, contenidas en los instrumentos de evaluación de la CV, pero de forma superficial y/o poco explícita, como en el SF-36, medio más frecuentemente identificado en los estudios de esta revisión. Estos hallazgos sugieren la posibilidad de implicaciones diferenciadas de esos instrumentos según la etiología de las lesiones, necesidades psicosociales y psicoespirituales del individuo, así como el contexto a que se destinan, tales quales enseñanza, práctica clínica o investigación. PALABRAS CLAVE (fuente: Decs) Calidad de vida; heridas y lesiones; úlcera de la pierna; evaluación; evaluación de programas e instrumentos de investigación. 3 Instruments to Assess the Subjective Repercussions of People with Chronic Wounds: Integrative Review l Joyce Souza Lemes e outros Instrumentos para avaliação das repercussões subjetivas de pessoas com feridas crônicas: revisão integrativa RESUMO Objetivo: analisar os instrumentos descritos na literatura para avaliação ampliada em pessoas com ferida crônica. Material e métodos: estudo de revisão integrativa da literatura. A busca foi feita nas bases de dados PUBMED, Web of Science, SciElo, CINAHL, Science Direct (Elsevier), Scopus, e Biblioteca Virtual da Saúde (BVS). Resultados: foram encontrados 19060 artigos; após os testes de relevância, restaram quatro. O instrumento mais utilizado nos estudos dessa revisão foi o SF-36, que é uma ferramenta de avaliação da qualidade de vida (QV). Conclusão: identificou-se diversidade de instrumentos para avaliação ampliada de pessoas com feridas, sendo os de investigação da QV os mais frequentes. As repercussões estão, em sua maioria, contidas nos instrumentos de avalição de QV, porém de forma superficial e/ou pouco explícita, como no Short Form 36 Health Survery (SF-36), meio mais frequentemente identificado nos estudos dessa revisão. Esses achados sugerem a possibilidade de implicações diferenciadas desses instrumentos conforme a etiologia das lesões, necessidades psicossociais e psicoespirituais do indivíduo, bem como o contexto a que se destinam, tais como ensino, prática clínica ou pesquisa. PALAVRAS-CHAVE (fonte: Decs) Qualidade de vida; ferimentos e lesões; úlcera da perna; avaliação; avaliação de programas e instrumentos de pesquisa. AÑO 19 - VOL. 19 Nº 1 - CHÍA, COLOMBIA - FEBRERO 2019 l e1918 4 AÑO 19 - VOL. 19 Nº 1 - CHÍA, COLOMBIA - FEBRERO 2019 AQUICHAN - ISSN 1657-5997 - eISSN 2027-5374 Introduction The occurrence of chronic wound, to the demands and limita- tions caused by the ulcer, triggers several representations to in- dividuals. 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 in- terpretations 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 Pa- tient 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 treat- ment, enable monitoring possible changes. These instruments serve as an aid because they estimate the evaluation in measur- able 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 pri- orities, 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 profession- als 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 forma- tion 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, con- ducted from August 2016 to July 2017. For the purpose of re- porting 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 pre- sentation 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 in- struments 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 com- plications in the feet due to diabetes mellitus, psoriasis), and also articles that use instruments for this evaluation. Disserta- tions, theses, book chapters, editorials, reviews, comments, ab- stracts, systematic and integrative review articles, and duplicate articles were excluded. 5 Instruments to Assess the Subjective Repercussions of People with Chronic Wounds: Integrative Review l Joyce Souza Lemes e outros On 16 February 2017, a search was conducted in the fol- lowing 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 “vari- cose ulcer” OR “pressure ulcer” OR “diabetic foot” AND “evalua- tion” 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 estab- lished from the research question (7). The study considered arti- cles 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, dis- sertations, 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 con- tinued 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 cat- egorizing 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 ad- dressing 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 se- lected, 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, indi- cating a growing demand for greater understanding on aspects con- cerning the extended assessment of people with chronic wounds. With regards to types of studies, 26 (63.4 %) were cross-sec- tional, 10 (24.4 %) validation, translation, and adaptation of instru- ments, two (4.9 %) were pilot studies, two (4.9 %) control cases, and one (2.4 %) cohort study. There was prevalence of research conducted in American countries (51.2 %), of which 76.2 % were Brazilian, followed by European studies (43.9 %). With respect to the authors’ formation area, 20 (48.8 %) were from Medicine, 11 (26.8 %) from Nursing, 6 (14.6 %) from Physiotherapy, and 4 (9.8 %) from Nutrition. 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 Figure 1. Flowchart of the study inclusion process Source: Own elaboration. 6 AÑO 19 - VOL. 19 Nº 1 - CHÍA, COLOMBIA - FEBRERO 2019 AQUICHAN - ISSN 1657-5997 - eISSN 2027-5374 Table 1. Characterization of the studies according to type, population, objective, conclusion, and level of evidence. Goiania, 2017. Nº Type of study Location of study Population Objective of the study Principal findings Level of evidenceAge Sex E1 (9) Exploratory, descriptive, cross- sectional Brazil < 60 41 % 60-70 58 % > 70 1 % More than 50 % F Observe and compare feelings of powerlessness in people with venous ulcer and in people with foot ulcer due to complications of Diabetes Mellitus (DM) using the Powerlessness Assessment Tool (PAT) scale. The results indicated that patients with venous disease e foot ulcer due to complications of DM had very strong feelings of powerlessness for living with this. Said feelings are significantly stronger in patients with foot ulcer due to complications of DM (P: 0.002). 4b E2 (10) Cross- sectional, descriptive and analytic study The United Kingdom Mean of 65 years 54 % F Test the Pressure Ulcer QOL (PU-QOL) among people with Pressure lesion (PL). The PU-QOL instrument provides a standardized method to assess QOL (QOL) specific of the pressure ulcer. 4b E3 (11) Cross- sectional, descriptive and analytic study Germany Mean of 67.8 years 55 % F Assess the level of pain of patients related to leg ulcer and determine the impact of said pain on the QOL of said patients, using the EQ 5D instrument. In 46 % of the participants with pain, it was identified that high levels of pain correlated with worse health status. Greater reduction of QOL was noted related to pain for women (R20.56, men; R20.08, women). 4b E4 (12) Cross- sectional comparative study Greece Mean 48.2 years 50 % F Compare QOL, anxiety and depression, self-esteem and feeling of loneliness in patients with psoriasis and leg ulcer (LU). Both groups present worse conditions of the items evaluated. People with psoriasis present greater loneliness, social isolation, and anxiety (p < 0.001) than people with LU. Self-esteem had no significant difference between the groups. 4b E5 (13) Observation- al, cross- sectional, analytic, multicenter study Spain Mean of 72.06 years 55 % M Determine QOL in patients with venous ulcer and the relation severity of the ulcer loss of QOL, as well as identify the aspects of QOL most negatively affected by the venous ulcer. Relationship exists between severity of the ulcer and lower QOL (r: 0.546; p ≤ 0.001). Presence of non-via- ble tissue, exudate and infection determine worse QOL. New studies are necessary to confirm said findings. 4b E6 (14) Cross- sectional, random multicenter study Canada Mean of 65 years 55 % F Observe the association between sociodemo- graphic and clinical factors and QOL in patients with chronic leg ulcer. Higher levels of pain (p < 0.01; CI = 1.3-4.7), lower age (p < 0.01; CI = 1.1-1.5), higher time of ulcer dura- tion (p < 0.01; CI = 1.7-5.0), limitation in mobility (p = 0.02; CI = 1.2-3.2) were associated to worse QOL. 1c E7 (15) Prospective non-random- ized cohort study The United Kingdom Mean of 69.7 years 76 % M Evaluate factors associated to the healing process and impact of the limb loss on the QOL of patients with foot ulcer due to complications of DM. 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 am- putation). Significant improvement was also observed in self-care after follow up. 3c E8 (16) Cross- sectional, descriptive, analytic study Brazil 31.7 % < 60 65 % 61-70 33 % > 70 73 % F Identify feelings of powerlessness among people with venous ulcer, from the (PAT) scale. High PAT scores were identified, revealing strong (32 %) or very strong (52 %) feelings of powerlessness, which can provoke negative effects on QOL. 4b E9 (17) Compara- tive, cross- sectional study Brazil Mean of 65 years 80 % F Evaluate QOL and self-esteem in patients with foot ulcer due to complications of DM. Patients with ulcer on diabetic foot present lower QOL regarding physical aspects (p = 0.043), functional capacity (p = 0.003), social aspects (p = 0.022), emotional aspects (p = 001). There was no statistical difference of self-esteem among groups of diabetic patients without ulcer. 4b 7 Instruments to Assess the Subjective Repercussions of People with Chronic Wounds: Integrative Review l Joyce Souza Lemes e outros Nº Type of study Location of study Population Objective of the study Principal findings Level of evidenceAge Sex E10 (18) Cross- sectional study India Mean of 62 years 58.5 % F Evaluate the impact of foot ulcer on QOL of diabetic patients, using the RAND 36 scale and the DFS scale. Diabetic patients with and without foot ulcer had impaired QOL (score ˂ 50 points). The group of patients with foot ulcer due to complication of DM presented compromised QOL in all six domains of DSF ― Short Form. Patients with foot ulcer due to complication of DM had worse QOL when compared to diabetic patients without ulcer. 4b E11 (19) Quantitative, descriptive and cross- sectional research Brazil 38 to 59 years 63.3 % F Analyze the impact of venous ulcers on the QOL of people attended in primary health care. Compromise of QOL was identified, the most affected dimensions were emotional state and aesthetics, especially in individuals with lesion for more than a year. Association was observed between current time of lesion and emotional state (p: 0.008), in which indi- viduals with lesion for more than one year had higher measurements (64.5). 4b E12 (20) Observa- tional cross- sectional study Portugal Mean 71.9 years 63.3 % F Evaluate the impact of chronic leg ulcers on QOL of patients in Portugal using the Nottingham Health Profile (NHP) scale, and verify changes after 12 weeks of treatment. Patients had high scores in all NPH domains. After 12 weeks, an increase was noted in all the dimensions of NPH and a statistically significant improvement, in pain (p: 0.003) and in the EuroQOL score (p: 0.027). 4b E13 (21) Control case The United States Mean of 57 years 80 % F Compare the QOL of patients with chronic neuropa- thy (Charcot) with and without ulcerations on the feet due to complications of DM. 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). 3d E14 (22) Cross- sectional study Czech Republic Mean of 64 years 72 % M 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 < 0.001). 4b E15 (23) Instrument validation study Colombia Mean of 78.6 years 63 % F Validate the Spanish version of the Charing Cross Venous Ulcer Questionnaire (CCVUQ-e). The CCVUQ-e has good internal consistency (Cron- bach’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. 4b E16 (24) Cross- sectional study Brazil Mean of 60 years 74.5 % F Compare the QOL of patients with chronic venous disease with and without ulcer and identify the most affected aspects. The QOL of patients with and without venous ulcer was different in the eight domains and in both dimensions of SF-36 (p < 0.05). The most affected aspects were: Physical aspect (p < 0.001), functional capacity (p < 0.001), social aspects (p < 0.001), and physical health (p < 0.001). People with venous ulcer had worse QOL when compared to people without that lesion. 4b E17 (25) A cross- sectional probabilistic study Brazil Mean of 52.8 years 62 % F Evaluate QOL and analyze the association between personal characteristics and health in QOL of patients with chronic leg ulcers. The sampling had better QOL (median = 21.6; SD = 3.4). The domain of health and functioning had the lowest scores (median = 19.7; SD = 3.7). Age (p = 0.0165), number of children (p = 0.0083), and religious practice (p = 0.0394) had significant positive effect on QOL. 4b 8 AÑO 19 - VOL. 19 Nº 1 - CHÍA, COLOMBIA - FEBRERO 2019 AQUICHAN - ISSN 1657-5997 - eISSN 2027-5374 Nº Type of study Location of study Population Objective of the study Principal findings Level of evidenceAge Sex E18 (26) Control case Greece Mean of 62.29 years 51 % M Evaluate QOL, anxiety, and depression, self-esteem and loneliness in patients with leg ulcer. Patients of female gender had a higher score of anxiety (p = 0.027) and social isolation (p = 0.048) and worse QOL (p = 0.018) than patients of male gender. A seri- ous compromise of QOL was observed, and reflected significant psychosocial impact in patients with leg ulcers (p < 0.05). 3d E19 (27) Descriptive cross- sectional study The United States Mean of 56.9 years 80 % M Compare QOL in patients with foot ulcer due to complications of DM with and without infection. Scores of the physical aspects (p < 0.001) and mental (p = 0.025) of SF-36 were significantly reduced in patients with infection indicated a negative effect on general health, besides a reduction in the function of the lower extremities (p < 0.001). 4b E20 (28) Validation longitudinal study Germany Mean of 65.3 years 54,5 % M Develop a questionnaire to evaluate QOL in people with chronic leg ulcers. The Wound-QOL has good internal consistency (Cron- bach’s alpha 0.71 to 0.91), convergent validity (r = 0.48 to 0.69) and responsiveness (r = 0.18 to 0.52). The Wound-QOL has satisfactory psychometric properties to assess QOL in people with leg ulcer in Germany. 4b E21 (29) Multicenter, prospective, descriptive, analytic study. Brazil Between 60 and 70 years Major- ity F Evaluate self-esteem and bodily image of patients with venous ulcer (VU). Low scores for bodily image (7.43), bodily care (5.71) and body touch (12.3) in patients with VU indicate negative feelings regarding the body (p < 0.05). In addition, the low score (22.66) for the Rosenberg Self- esteem (RSE) scale also indicates low self-esteem in these patients (p < 0.05). E22 (30) Cross- sectional, translation and cultural adaptation study Brazil Mean of 56.2 years 100 % F Translate and adapt the Charing Cross Venous Ulcer Questionnaire for a Brazilian population. In the process of translation and adaptation, some terms needed to be changed to facilitate their compre- hension. The Charing Cross Venous Ulcer Questionnaire was translated and adapted for use in a Brazilian population. 4b E23 (31) Cross- sectional, translation and cultural adaptation study Brazil Mean of 67.3 years 68 % F Translate the Venous Leg Ulcer QOL Questionnaire (VLU-QOL) into Brazilian Portuguese, culturally adapt, and validate the VLU-QOL-Br questionnaire for the Brazilian population. The instrument has high internal consistency (Cron- bach’s alpha: 0.94), good reproducibility (interclass correlation coefficient: 0.78; p ˂ 0.01), the confirmatory analysis maintained the same domains of the original version of the instrument. The instrument has satisfac- tory psychometric properties, which permits its use in Brazil. It is recommended to evaluate its performance in other regions and in different samples of individuals. 4b E24 (32) Cross- sectional instrument validation Brazil Mean of 63.2 years 80 % F Validate the Charing Cross Venous Ulcer Question- naire for the Brazilian population. The instrument has good internal consistency (Cron- bach’s alpha: 0.92), high correlation in the evaluation of inter-observer reproducibility and its stability, presents inter-class correlation coefficients above 0.80 for all domains. Furthermore, the instrument presented reasonable correlations with the SF-36 domains. The CCVUQ-Brazil is validated in Portuguese. 4b E25 (33) Multicenter, randomized instrument validation study The United Kingdom Mean of 68.6 years 50.07 M Validate the VEINES-QOL to evaluate QOL in people with venous ulcer. The instrument has good internal consistency (Cronbach’s alpha: 0.88), reproducibility (interclass correlation coefficient: 0.80), adequate correlation with the components of the SF-12, and moderate responsiveness. 1c E26 (34) Cross- sectional study Brazil Mean of 60 years 53.6 % F Evaluate a QOL in people with foot ulcer due to complications of DM and its association with age and gender. Participants presented domains of QOL that tend to have a worse health status, however, there was no significant difference in the results between groups regarding age and gender. 4b 9 Instruments to Assess the Subjective Repercussions of People with Chronic Wounds: Integrative Review l Joyce Souza Lemes e outros Nº Type of study Location of study Population Objective of the study Principal findings Level of evidenceAge Sex E27 (35) Translation and cultural adaptation study Uruguay Mean of 63.4 years 52 % F Translate and adapt the Charing Cross Venous Ulcer Questionnaire (CCVUQ) for Uruguay. The translation and adaptation of the version of CCVUQ was easy to understand and apply, showing adequate psychometric properties. 4b E28 (36) Obser- vational longitudinal study Germany Mean of 62 years 60 % F Validate the Freiburg Life Quality Assessment instrument to evaluate QOL in people with venous ulcer. The instrument presented good internal consistency (Cronbach’s alpha: ≥ 0.85), reliability, convergent validity with the EuroQOL questionnaire of QOL (EQ-5D) and sensitivity to change (r: 0.59-0.61). E29 (37) Cross- sectional analytic study Brazil Mean of 55 years 60 % F Evaluate QOL and depression in elderly patients with PL. Patients with LU had significantly low QOL scores, when compared to the control group, in all domains of the Short Form-36 (SF-36), with lower scores in the domains physical function and emotional function (P < 0.0001). Seventy (80.9 %) patients had depression (P = 0.002). 4b E30 (38) Cross- sectional pilot study The United Kingdom Mean of 70 years 58 % F Determine the impact of PL in (QOL) in people with PL. PL impacts QOL negatively, independent of concomitant comorbidities (diabetes, arthritis, CVA, cancer, ortho- pedic, respiratory, neurological. In spite of borderline significance (p = 0.06), the pain perceived is higher among people with LP. 4b E31 (39) Cross- sectional multicenter study Italy Mean of 60 years 61 % F Access pain and QOL in patients with chronic leg ulcer. Leg ulcers are painful and result in low QOL that is directly related to the time of duration of the lesion and its area. 4b E32 (40) Cross- sectional analytic Turkey Between 30 and 51 years 65 % M Determine the correlation between depression and level of social support perceived of people with foot ulcers due to complications of DM. Depression and social support perceived correlate with foot ulcers due to complications of DM (p < 0.01). 4b E33 (41) Translation and adapta- tion of the instrument Poland Mean of 62.5 years 70 % F Translate into Polish the Diabetic Foot Ulcer Scale (DFS). The translated instrument can be used in Polish patients. 4b E34 (42) Cross- sectional pilot study Poland Mean of 56 years 75 % F Compare QOL of people with vascular ulcers and those with chronic venous insufficiency (CVI), without ulcer. Significant differences were observed (p < 0.05) on the QOL of people with vascular ulcers and people with CVI without chronic ulcer. 4b E35 (43) Methodolog- ical study to adapt and validate the instrument Brazil Mean of 55.7 years 54 % F Adapt into Brazilian Portuguese and test reliability and validity of the Brazilian version of the Neuropa- thy ― and Foot Ulcer ― Specific QOL Instrument ― (NeuroQOL) to people with diabetic neuropathy with foot ulcers. The findings evidence psychometric properties that con- firm validity and reliability to NeuroQOL, with cultural adaptation being necessary in other regions of Brazil. Statistically significant correlations (p < 0.01) were verified in domains of pain and mental component, loss of sensitivity and physical component, anguish and physical component, activities of daily life and physical component. 4b E36 (44) Analytic, cross-sec- tional, con- trolled, and comparative study Brazil Mean of 55 years 62 % F Evaluate the QOL of people with DM with foot ulcer in relation to people with DM without ulcer. In patients from the control group, the mean score of the SF-36 was 69.38 ± 21.90 and from the study group, 30.34 ± 14.45 (P < 0.001). The mean scores in all SF- 36 domains of the study group were lower in relation to the control group (P < 0.001); thus, demonstrating that diabetic patients with foot ulcer present changes in QOL, which impacts multi-dimensionally. 4b E37 (45) Cross- sectional study The United Kingdom Mean of 62 years 60 % M Evaluate anxiety and depression of people with Charcot foot due to complication of DM, compared with diabetic individuals without foot complications. Patients with Charcot foot had high levels of mental problems when compared to patients without ulcer. Anxiety and depression had high scores, 6.4 ± 4 and 6.3 ± 3.6, respectively. The risk of anxiety was not significant, but the risk of depression was significant (p < 0.05). 4b 10 AÑO 19 - VOL. 19 Nº 1 - CHÍA, COLOMBIA - FEBRERO 2019 AQUICHAN - ISSN 1657-5997 - eISSN 2027-5374 Source: Own elaboration. Nº Type of study Location of study Population Objective of the study Principal findings Level of evidenceAge Sex E38 (46) Cross- sectional study Brazil Mean of 61 years 59 % F Evaluate level and intensity of depression of patients with chronic wounds (venous ulcer, pres- sure lesion, foot ulcer due to DM) from the Beck inventory. Among patients with venous ulcer, 7 (28 %) had slight to moderate depression and 3 (12 %) had moderate to serious depression. Sixteen (53.3 %) patients with pressure ulcers manifested slight to moderate depres- sion, and 5 (16.7 %), moderate to serious depression; 10 (55.6 %) diabetic patients with foot ulcer had slight to moderate depression, and 4 (22.20 %) without depression or minimum depression. 4b E39 (47) Exploratory, descriptive, and cross- sectional study Brazil Between 60 and 69 years 60 % F Evaluate the intensity of depression and depressive symptoms in diabetic patients with foot ulcers. Diabetic patients with foot ulcers had varying degrees of depressive symptoms, with prevalence of “moder- ate” level (64 %) and symptoms: Self-depreciation, sad- ness, 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). 4b E40 (48) Cross- sectional prospective study The United States Mean of 64.1 years 52 % M It is determined that depression is associated to increased incidence of foot ulcers of patients with type 2 diabetes. Compared to patients without depression, patients with higher depression have greater risk of having foot ulcer due to complications of DM (CI = 1.24 – 3.25). There was no statistically significant association within minor depression. 4b E41(49) Cross- sectional study Norway 20 years or more 60 % F Compare levels of anxiety and depression, psy- chological wellbeing and health perception among people with diabetes, with or without history of foot ulcer, and people from the community without diabetes. Anxiety, depression, and perceived health had interac- tion with age and presence of DM (p = 0.002). 4b hypertension (19.7 %), heart disease (7.3 %), orthopedic trauma (4.8 %), neurological disorders (2.4 %), and cancer (2.4 %). The 11 studies that evaluated schooling of the participants identified com- plete primary education in seven (63.6 %), and four (36.4 %) with more than half the population being illiterate. 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 dia- betes mellitus (DM), 16 (42. %) venous ulcer, two (5.2 %) arterial ulcer, one (2.6 %) neuropathic ulcer, one (2.6 %) compared popula- tions 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 in- vestigations. 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. The most notable repercussion in the studies was QOL, identi- fied in each in 35 (85.3 %) studies, followed by “pain” in five (12.2 %), self-esteem in five (12.2 %), depression in five (12.2 %), anxiety and depression, together, in four (9.7 %), feeling of powerless- ness in two (4.8 %), loneliness in two (4.8 %), perceived social support in one (2.4 %), and general health in one (2.4 %) study. Considering the studies (n = 35, 85.3 %) that evaluated QOL, concomitantly, three studies (8.5 %) evaluated bio-physiological di- mensions, sought correlations with QOL. Of these, one (33.3 %) evalu- ated 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 11 Instruments to Assess the Subjective Repercussions of People with Chronic Wounds: Integrative Review l Joyce Souza Lemes e outros Table 2. Human impacts and respective instruments of extended assessment applied among people with chronic wounds. Goiania, 2017 Impact assessed Name of the instrument Frequency (n, %) / Studies Population for which the instrument was elaborated Description of the instrument QOL 36-Item Short-Form Health Survey* (SF-36) 8 19.5 % E9, E13, E16, E19, E26, E30. E35, E36 Adults in diverse clinical situations SF-36 is comprised of 36 items encompassed in eight components: Functional capacity (10 items), physical aspects (four items), pain (two items), general state of health (five items), vitality (four items), social aspects (two items), emotional aspects (three items), mental health (five items), and one compara- tive question on the current perception of health and one year ago. The Charing Cross Venous Ulcer Ques- tionnaire (CCVUQ) 6 14.6 % E5, E11, E15, E22, E24, E27 People with venous ulcer CCVUQ is composed of 21 items that identify four important domains of health: Social interaction, domestic activities, aesthetics, and emotional state, yielding scores of 0 - 100 in which a higher score indicates worse QOL. Diabetic Foot Ulcer Scale-Short Form (DFS-SF)* 4 9.7 % E7, E10. E14, E33 Patients with foot ulcer due to compli- cations of DM DFS-SF consists in 58 items (each in a 5-point Likert-type scale) grouped into 11 domains: Leisure, physical health, daily activities, emotions, noncompliance, family, friends, treatment, satisfaction, positive attitudes, financial. 12-Item Short- Form Health Survey (SF-12) 3 7.3 % E6, E25, E31 Adults in diverse clinical situations SF-12 is a reduced version of the SF-36, composed of 12 items that evaluate two big components: The physical component or physical component score (PCS) and the mental component or mental component score (MCS). The scores vary from 0 to 100 in which 0 represents worse QOL and 100 better QOL. Dermatology Life Quality Index (DLQI)* 2 4.8 % E4, E18 Patients with dermatological problems 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. 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), iden- tified in eight (44.4 %) studies, and the Charing Cross Venous Ul- cer 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 ac- tivities of daily life, identified in 13 (72.2 %) instruments. Ques- tions 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 ac- cording to the etiology of the ulcers, through most commonly observed symptoms. In relation to the other repercussions, four instruments iden- tified were used, each, in four (12.1 %) studies: Diabetic Foot Ulcer Scale (DFS), Visual Analog Scale (VAS), Rosenberg Self- esteem 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 Powerless- ness Assessment Tool (PAT) questionnaire, and Loneliness scale (UCLA) were each used in two (6.1 %) studies. 12 AÑO 19 - VOL. 19 Nº 1 - CHÍA, COLOMBIA - FEBRERO 2019 AQUICHAN - ISSN 1657-5997 - eISSN 2027-5374 Impact assessed Name of the instrument Frequency (n, %) / Studies Population for which the instrument was elaborated Description of the instrument QOL EQ-5D Question- naire* 2 4.8 % E3, E30 People with chronic ulcer It includes a scale from 0 to 100 points, and is divided into eight domains: Mobility, personal care, activities of daily life, pain and discomfort, anxiety and depression. The answers register three levels of severity (without any problems or moderate problems, external problems). Freiburg Life Quality Assessment (FLQA-w)* 2 4.8 % E20. E28 Patients with chronic wounds FLQA-w consists of 6 domains: Physical symptoms, daily life, social life, psycho- logical wellbeing, treatment, and satisfaction. The calculation of the domains is carried out by the arithmetic mean of each response, after recoding the satis- faction domain. The total score is through the mean values of the domains. QOL index by Fer- rans and Powers ― version wounds 1 2.4 % E17 People with acute and chronic wounds This instrument has 35 items distributed into four domains: Health and function- ing, socioeconomic, psychological/spiritual and family. The total score and for each domain varies from 0 (worse QOL) to 30 (better QOL). The RAND 36-Item Health Survey (RAND-36) 1 2.4 % E10 People with chronic wounds It has 36 items divided into eight domains: Physical functioning, bodily pain, function limitations due to problems of physical health, function limitations due to personal or emotional problems, emotional wellbeing, social functioning, energy/fatigue and general perceptions of health. Venous Leg Ulcer QOL Questionnaire (VLU-QOL) 1 2.4 % E23 People with venous ulcers These are 34 questions divided into three dimensions: Activities, psychological, and symptoms of the ulcer. The score is made by the Likert scale, varying from 0 (never) to 100 (always). Venous Insufficien- cy Epidemiological and Economic Study ― QOL/Symptom (VEINES-QOL) 1 2.4 % E25 People with venous insufficiency 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. Pressure Ulcer ― QOL Instrument (PU-QOL instru- ment) 1 2.4 % E2 Patients with pres- sure lesion PU-QOL contains 10 domains: Pain, exudate, smell, sleep, mobility, activity, vital- ity, emotional, wellbeing, and self-concept. Patients assess "nuisance" level as- signed 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. The Skindex-29 questionnaire 1 2.4 % E34 Patients with dermatological conditions Skindex-29 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. Neuropathy ― and Foot Ulcer ― Specific QOL ― NeuroQOL 1 2.4 % E35 People with diabetic neuropathy and foot ulcer Composed by 35 items distributed into six domains: Pain, reduction of sensitiv- ity, 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. 13 Instruments to Assess the Subjective Repercussions of People with Chronic Wounds: Integrative Review l Joyce Souza Lemes e outros Impact assessed Name of the instrument Frequency (n, %) / Studies Population for which the instrument was elaborated Description of the instrument QOL Nottingham Health Profile (NHP)* 1 2.4 % E12 Adults in diverse clinical situations Divided into six domains: Level of energy, pain, emotional, sleep, social and physical abilities. The score varies between 0 and 100, higher values represent more negative interference QOL. Wound QOL* 1 2.4 % E20 People with chronic wounds Composed of 17 items, with three domains: Daily life, bodily, and psychologi- cal. 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). The Cardiff Wound Impact Schedule (CWIS)* 1 2.4 % E20 People with chronic wounds CWIS consists of three domains: Wellbeing, physical symptoms, social life, and daily life. Scores vary from 0 to 100, in which higher values indicate better QOL. Würzburg Wound Score (WWS)* 1 2.4 % E20 People with chronic wounds WWS is composed of 17 items related to pain, sleep, happiness, frustration, worry, smell, discomfort, fear, activities of daily life, mobility, limitation, depen- dence, and financial. Pain Visual Analog Scale (VAS)* 4 9.7 % E12, E14, E30. E33 Adults in diverse clinical situations VAS provides a one-dimensional measurement of pain intensity. It has anchors of 0 (without pain) to 10 (worse pain possible). McGill Pain Ques- tionnaire (MPQ) 1 2.4 % E6 Adults in diverse clinical situations Seeks to provide qualitative measurements of pain that can be analyzed statisti- cally. 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 Invest- ment 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, vary- ing 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. Depression Beck’s Depression Assessment Inven- tory* 3 7.3 % E32, E38, E39 Destined for pa- tients over 13 years of age Consists of 21 categories and each category has 4 points. The highest score is 63; the higher the score, higher degree of intensity of depression. 0 to 10 indicates no symptom of depression, 11 to 17 indicates few symptoms, 18 to 29, moderate, and 30 to 63 indicates high level of depressive symptoms. 15-item Geriatric Depression Scale 1 2.4 % E 29 Destined for elderly patients Consists of 15 questions made in interview form with ‘yes or no’ answers, which evaluate if the elderly patient has or does not have depressive symptoms. Patient Health Questionnaire-9 (PHQ-9) 1 2.4 % E40 Adults in diverse clinical situations Composed of nine questions that evaluate the presence of nine symptoms of depression: Depressed mood, anhedonia, problems sleeping, tiredness, change in appetite or weight, feeling of guilt or uselessness, lack of concentration, feeling slow or 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. 14 AÑO 19 - VOL. 19 Nº 1 - CHÍA, COLOMBIA - FEBRERO 2019 AQUICHAN - ISSN 1657-5997 - eISSN 2027-5374 Source: Own elaboration. Impact assessed Name of the instrument Frequency (n, %) / Studies Population for which the instrument was elaborated Description of the instrument Feeling of powerless- ness Powerlessness Assessment Tool (PAT) 2 4.8 % E1, E8. Adults in post- operatory The instrument consists of a measure of 12 items distributed into three domains: Capacity to perform behavior, perception of the capacity to make deci- sions, 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. Loneliness UCLA Loneliness scale (version 3)* 2 4.8 % E4, E18 Not shown by study UCLA (Version 3) is a questionnaire with 20 items that measures the personal perception of loneliness and of social isolation. The stronger these feelings were, the higher the UCLA score. Perceived social support Multidimensional scale of perceived social support* 1 2.4 % E32 Adults in diverse clinical situations Consists of 12 items, evaluates the perception of adequate support perceived by 3 domains: 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. Healing Pressure ulcer scale of healing (PUSH) 1 2.4 % E15 People with pres- sure lesion 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. Functionality Foot and Ankle Ability Measure- ment (FAAM) 1 2.4 % E19 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. Cognition Mini Mental – men- tal exam 1 2,4 % E29 Adults in diverse clinical situations Mini-mental State consists of a test to examine the mental state that assesses orientation, memory, attention, and language. Higher scores indicate better cognitive performance. The maximum score is 30 points. Due to the influence of schooling on the total scores of the Mini-mental State, the evaluation of the result occurs according to the schooling of the individuals. *Instruments used concomitantly for at least one more instrument, and not in isolated manner, in the studies. 15 Instruments to Assess the Subjective Repercussions of People with Chronic Wounds: Integrative Review l Joyce Souza Lemes e outros Discussion Regarding the design diversity of the studies included, it is as- sociated with the research question of this review that sought to know the instruments introduced in the literature for extended as- sessment 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, mak- ing 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 in- vestigations on this theme. Nursing still needs further investment to carry out studies like these, given that it is one of the profes- sional 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 addi- tion, 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 lit- erature for the etiologies identified (50). This fact points to the pres- ence of specific profiles that may help in directing actions in the context studied. It is possible to identify association between sociodemo- graphic data and psychosocial repercussions, like the highest oc- currence 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). An- other 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 con- tinuous 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 re- lation 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 fre- quent 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 affirma- tion in different clinical and cultural contexts. The diversity of instruments existing in the literature to as- sess 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 vari- ables, like clinical practice, teaching, and research, which needs validation by other studies. Evaluation of QOL, as the most frequent outcome investigat- ed 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 su- perficial 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 instru- ments can be tracers and not determinants in judging the pres- ence 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 inad- equately 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. Addition- ally, 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 mea- suring the efficacy and response to treatment, and influences the prognosis (19, 22, 28, 29, 30, 46, 47). Pain represents an infec- tious 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 recommend- ed 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). 16 AÑO 19 - VOL. 19 Nº 1 - CHÍA, COLOMBIA - FEBRERO 2019 AQUICHAN - ISSN 1657-5997 - eISSN 2027-5374 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 instru- ments 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 justi- fied because it is an instrument that addresses a greater diver- sity 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 re- percussions 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 systematiza- tion 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 instru- ments analyzed were: Anxiety, depression, loneliness, self-esteem, feelings of powerlessness, and perceived social support, in addi- tion 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 re- percussions, but they hinder more directed judgment. The findings in this research reinforce the contributions of us- ing 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 psycho- spiritual 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 vari- ous scenarios to indicate their evidence in a directed and, conse- quently, safer manner. Conflict of interest: None declared. 17 Instruments to Assess the Subjective Repercussions of People with Chronic Wounds: Integrative Review l Joyce Souza Lemes e outros References 1. Oliveira MO, Pereira Jr AC, Pinto JSF, Vieira NF, Wichr P. Significado da ferida para portadores de úlceras cônicas. Cogit Enferm. 2011; 16(3): 471-7. DOI: 10.5380/ce.v16i3.20178 2. Wounds UK. 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