Assessment of chronic wounds in adults: an integrative review

Few studies exclusively address wound assessment. However, the review found many aspects to consider when assessing individuals with ulcers, grouped as follows: factors that significantly affect healing or the development of new wounds (age, nutritional status, functional capacity, or comorbidities), pyschosocial factors, and wound characteristics (location, size, depth, type of tissue, time of evolution).

Conclusion:

The literature search did not result in any one aspect that must be considered when assessing chronic wounds, but a complex interaction of factors that include both physiological and social and psychological elements. Professionals should be aware of this multifactorial approach to achieve early detection of the development and evolution of ulcers and to intervene accordingly.

DESCRIPTORS
Ulcer; Wounds and Injuries; Wound Healing; Risk Factors; Nursing Assessment; Review

Author	Year	Main objective	Results/Conclusions
Lizaka⁽¹⁰10. Lizaka S, Okuwa M, Sugama J, Sanada H. The impact of malnutrition and nutrition-related factors on the development and severity of pressure ulcers in older patients receiving home care. Clin Nutr. 2010;29(1):47-53. DOI: 10.1016/j.clnu.2009.05.018 https://doi.org/10.1016/j.clnu.2009.05.0... ⁾	2010	To investigate the impact of the nutritional status of home care patients with Pus	Malnutrition was associated with the development of PUs.
Takahashi⁽¹¹11. Takahashi PY, Chandra A, Cha SS. Risk factors for pressure ulceration in an older community-dwelling population. Adv Skin Wound Care. 2011;24(2):72-7. DOI: 10.1097/01.ASW.0000394030.49530.b4 https://doi.org/10.1097/01.ASW.000039403... ⁾	2011	To determine risk factors for future PUs.	Age and comorbid medical conditions.
Bergquist⁽¹²12. Bergquist-Beringer S, Gajewski BJ. Outcome and assessment information set data that predict pressure ulcer development in older adult home health patients. Adv Skin Wound Care. 2011;24(9):404-14. DOI: 10.1097/01.ASW.0000405215.49921.a9 https://doi.org/10.1097/01.ASW.000040521... ⁾	2011	To identify risk factors for developing PUs at home.	Incontinence, level of dependency, and prior presence of PUs.
Michel⁽¹³13. Michel JM, Willebois S, Ribinik P, Barrois B, Colin D, Passadori Y. As of 2012, what are the key predictive risk factors for pressure ulcers? Developing French guidelines for clinical practice. Ann Phys Rehabil Med. 2012;55(7):454-65. DOI: 10.1016/j.rehab.2012.08.003 https://doi.org/10.1016/j.rehab.2012.08.... ⁾	2012	To identify the predicting factors of PUs.	Immobility and malnutrition
Coleman⁽¹⁴14. Coleman S, Gorecki C, Nelson EA, Closs SJ, Defloor T, Halfens R, et al. Patient risk factors for pressure ulcer development: systematic review. Int J Nurs Stud. 2013;50(7):974-1003. DOI: 10.1016/j.ijnurstu.2012.11.019 https://doi.org/10.1016/j.ijnurstu.2012.... ⁾	2013	To identify independent predicting risk factors of PU.	There is a complex interaction among different factors.
Joseph⁽¹⁵15. Joseph J, Clifton SD. Nurses’ knowledge of pressure ulcer risk assessment. Nurs Stand. 2013;27(33):54, 56, 58-60. DOI: 10.7748/ns2013.04.27.33.54.e7057R1TVS https://doi.org/10.7748/ns2013.04.27.33.... ⁾	2013	To explore the literature about the use of tools by nurses to assess risk and identify patients at greater risk to develop PUs.	Assessment must be a combination of knowledge, clinical judgment and scales.
McGinnis⁽¹⁶16. McGinnis E, Greenwood DC, Nelson EA, Nixon J. A prospective cohort study of prognostic factors for the healing of heel pressure ulcers. Age Ageing. 2014;43(2):267-71. DOI: 10.1093/ageing/aft187 https://doi.org/10.1093/ageing/aft187... ⁾	2013	To identify the characteristics of patients and ulcers associated with healing of heel PUs.	Increased severity of ulcer and presence of peripheral arterial disease were related to poor prognosis.
García⁽¹⁷17. Garcia-Fernandez FP, Pancorbo-Hidalgo PL, Soldevilla Agreda JJ. predictive capacity of risk assessment scales and clinical judgment for pressure ulcers: a meta-analysis. J Wound Ostomy Continence Nurs. 2014;41(1):24-34. DOI: 10.1097/01.WON.0000438014.90734.a2 https://doi.org/10.1097/01.WON.000043801... ⁾	2014	To determine the capacity of risk assessment scales and clinical judgment of nurses to predict development of PUs.	Assessment must take into account clinical judgment and the use of validated scales.
Alex⁽¹⁸18. Alex R, Ratnaraj B, Winston B, Samson Devakiruba DN, Samuel C, John J, et al. Risk factors for foot ulcers in patients with diabetes mellitus - a short report from vellore, South India. Indian J Community Med [Internet]. 2010 [cited 2015 Apr 29];35(1):183-5. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888355/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾	2010	To examine the risk factors for ulcers on patients with diabetes mellitus.	Insulin therapy, peripheral neuropathy, age, gender, callosity, deformities and ulcers.
Ikem⁽¹⁹19. Ikem R, Ikem I, Adebayo O, Soyoye D. An assessment of peripheral vascular disease in patients with diabetic foot ulcer. Foot (Edinb). 2010;20(4):114-7. DOI: 10.1016/j.foot.2010.09.002 https://doi.org/10.1016/j.foot.2010.09.0... ⁾	2010	To assess the risk factors associated with diabetic foot ulcers.	Patients presented risk factors for peripheral arterial disease, their diagnosis could be made using a handheld Doppler.
Altenburg⁽²⁰20. Altenburg N, Joraschky P, Barthel A, Bittner A, Pöhlmann K, Rietzsch H, et al. Alcohol consumption and other psycho-social conditions as important factors in the development of diabetic foot ulcers. Diabet Med. 2011;28(2):168-74. DOI: 10.1111/j.1464-5491.2010.03151.x https://doi.org/10.1111/j.1464-5491.2010... ⁾	2011	To characterize the bio-psycho-social factors associated with the development of diabetic foot ulcers.	Patients with diabetic foot tend to present less conscientious health behaviors.
Apelqvist⁽²¹21. Apelqvist J, Elgzyri T, Larsson J, Löndahl M, Nyberg P, Thörne J. Factors related to outcome of neuroischemic/ischemic foot ulcer in diabetic patients. J Vasc Surg. 2011;53(6):1582-8. DOI: 10.1016/j.jvs.2011.02.006 https://doi.org/10.1016/j.jvs.2011.02.00... ⁾	2011	To identify factors related to healing among patients with diabetic foot ulcers and peripheral vascular disease.	Comorbidity, extent of affected tissue and severity of peripheral vascular disease.
Monteiro⁽²²22. Monteiro-Soares M, Boyko EJ, Ribeiro J, Ribeiro I, Dinis-Ribeiro M. Predictive factors for diabetic foot ulceration: a systematic review. Diabetes Metab Res Rev. 2012;28(7):574-600. DOI: 10.1002/dmrr.2319 https://doi.org/10.1002/dmrr.2319... ⁾	2012	To identify studies about factors associated with diabetic foot.	Neuropathy, peripheral vascular disease, foot deformity and prior ulcers or amputation.
Moura Neto⁽²³23. Moura Neto A, Zantut-Wittmann DE, Fernandes TD, Nery M, Ribeiro Parisi MC. Risk factors for ulceration and amputation in diabetic foot: study in a cohort of 496 patients. Endocrine. 2013;44(1):119-24. DOI: 10.1007/s12020-012-9829-2 https://doi.org/10.1007/s12020-012-9829-... ⁾	2013	To determine the epidemiological presentation of diabetic foot and understand whether there are easily assessed variables capable of predicting the development of the diabetic foot.	Predictors of diabetic foot were being male and the presence of neuropathy. The combination of neuropathy and peripheral vascular disease significantly increased risk of amputation.
Pickwell⁽²⁴24. Pickwell KM, Siersma VD, Kars M, Holstein PE, Schaper NC. Diabetic foot disease: impact of ulcer location on ulcer healing. Diabetes Metab Res Rev. 2013;29(5):377-83. DOI: 10.1002/dmrr.2400 https://doi.org/10.1002/dmrr.2400... ⁾	2013	To assess the influence of ulcer location (diabetic foot).	Worse results found for heel ulcers, followed by midfoot and toe ulcers.
Baba⁽²⁵25. Baba M, Davis WA, Davis TME. A longitudinal study of foot ulceration and its risk factors in community-based patients with type 2 diabetes: the Fremantle Diabetes Study. Diabetes Res Clin Pract. 2014;106(1):42-9. DOI: 10.1016/j.diabres.2014.07.021 https://doi.org/10.1016/j.diabres.2014.0... ⁾	2014	To determine the prevalence and associated factors of foot ulcers among community-based patients with type 2 diabetes.	Peripheral sensitive neuropathy was a significant risk factor. However, peripheral arterial disease was also an important independent contributing factor.
Siersma⁽²⁶26. Siersma V, Thorsen H, Holstein PE, Kars M, Apelqvist J, Jude EB, et al. Importance of factors determining the low health-related quality of life in people presenting with a diabetic foot ulcer: the Eurodiale study. Diabet Med. 2013;30(11):1382-7. DOI: 10.1111/dme.12254 https://doi.org/10.1111/dme.12254... ⁾	2014	To identify factors responsible for low health-related quality of life associated with foot ulcers and the relative importance of these factors.	Treatment requires a multifactorial approach, going beyond just healing ulcers.
Iversem⁽²⁷27. Iversen MM, Tell GS, Espehaug B, Midthjell K, Graue M, Rokne BB, et al. Is depression a risk factor for diabetic foot ulcers? 11-years follow-up of the Nord-Trondelag Health Study (HUNT). J Diabetes Complications. 2015;29(1):20-5. DOI: 10.1016/j.jdiacomp.2014.09.006 https://doi.org/10.1016/j.jdiacomp.2014.... ⁾	2015	To prospectively examine whether depressive symptoms increase risk of diabetes and diabetic foot ulcers.	Depressive symptoms were associated with a higher risk of ulcers.
Fawzy⁽²⁸28. Fawzy OA, Arafa AI, El Wakeel MA, Abdul Kareem SH. Plantar pressure as a risk assessment tool for diabetic foot ulceration in egyptian patients with diabetes. Clin Med Insights Endocrinol Diabetes [Internet]. 2014 [cited 2015 Apr 29];7:31-9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4257475/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾	2014	To study the relationship between plantar pressure and neuropathy with or without ulceration.	Individuals with diabetes that presented neuropathy and/or ulcers presented elevated plantar pressure.
Nehring⁽²⁹29. Nehring P, Mrozikiewicz-Rakowska B, Krzyżewska M, Sobczyk-Kopcioł A, Płoski R, Broda G, et al. Diabetic foot risk factors in type 2 diabetes patients: a cross-sectional case control study. J Diabetes Metab Disord [Internet]. 2014 [cited 2015 Apr 9];13:79. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4128535/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾	2014	To compare risk factors for diabetic foot among the population with type 2 diabetes and risk factors for diabetes among healthy individuals.	Patients who were inclined to develop diabetic foot presented different risk factors than the patients who were at risk for diabetes.
Moffatt⁽³⁰30. Moffatt CJ, Doherty DC, Smithdale R, Franks PJ. Clinical predictors of leg ulcer healing. Br J Dermatol. 2010;162(1):51-8. DOI: 10.1111/j.1365-2133.2009.09397.x https://doi.org/10.1111/j.1365-2133.2009... ⁾	2010	To determine factors associated with healing among patients with chronic leg ulcers of any type.	Duration of ulcer, deep vein thrombosis and absence of infection.
Dinh⁽³¹31. Dinh T, Tecilazich F, Kafanas A, Doupis J, Gnardellis C, Leal E, et al. Mechanisms involved in the development and healing of diabetic foot ulceration. Diabetes. 2012;61(11):2937-47. DOI: 10.2337/db12-0227 https://doi.org/10.2337/db12-0227... ⁾	2012	Hypothesis: changes in the peripheral nerve function and the diabetes-associated proinflammatory state are related not only to the development of diabetic foot but with wound-healing failure.	Increased inflammation, expression of matrix metalloproteinase-9 and serum levels of fibroblast growth factor were associated with non-healing.
Gil⁽³²32. Gil T, Pistunovich Y, Kulikovsky M, Elmalah I, Krausz Y, Mettanes I, et al. A prospective case-control study of non-healing wounds of the lower limbs - the value of biopsies for ulcerating carcinoma. J Eur Acad Dermatol Venereol. 2015;29(2):337-45. DOI: 10.1111/jdv.12550 https://doi.org/10.1111/jdv.12550... ⁾	2015	Hypothesis: there is an underlying malignancy that could explain the chronic and non-healing nature of wounds.	The prevalence of malignancy may be greater than expected, thus it should be assessed through a biopsy.
Abolfotoub⁽³³33. Abolfotouh MA, Alfaifi SA, Al-Gannas AS. Risk factors of diabetic foot in central Saudi Arabia. Saudi Med J. 2011;32(7):708-13.⁾	2011	To identify risk factors for diabetic foot among diabetic patients.	Duration of diabetes, neuropathy, level of erythrocyte sedimentation rate.
Nehring⁽³⁴34. Nehring P, Makowski A, Mrozikiewicz-Rakowska B, Sobczyk-Kopcioł A, Płoski R, Karnafel W. Risk factors of diabetic foot of neuropathic origin in patients with type 2 diabetes. Endokrynol Pol. 2015;66(1):10-4. DOI: 10.5603/EP.2015.0003 https://doi.org/10.5603/EP.2015.0003... ⁾	2015	To identify risk factors of diabetic foot of neuropathic origin occurrence in patients with type 2 diabetes.	Male gender, duration of diabetes, height, weight, and waist circumference.
Parker⁽³⁵35. Parker CN, Finlayson KJ, Shuter P, Edwards HE. Risk factors for delayed healing in venous leg ulcers: a review of the literature. Int J Clin Pract. 2015;69(9):967-77. DOI: 10.1111/ijcp.12635 https://doi.org/10.1111/ijcp.12635... ⁾	2015	To review the available evidence on risk factors for delayed healing of venous leg ulcers.	Larger ulcer area and longer ulcer duration, previous ulcers, venous abnormalities and lack of high compression.
Francia⁽³⁶36. Francia P, Seghieri G, Gulisano M, De Bellis A, Toni S, Tedeschi A, et al. The role of joint mobility in evaluating and monitoring the risk of diabetic foot ulcer. Diabetes Res Clin Pract. 2015;108(3):398-404. DOI: 10.1016/j.diabres.2015.04.001 https://doi.org/10.1016/j.diabres.2015.0... ⁾	2015	To assess how ankle joint mobility can be useful in the identification of patients with diabetes at risk of foot ulcers.	The evaluation of ankle joint mobility can indicate which foot is at higher ulcer risk.
St-Supery⁽³⁷37. St-Supery V, Tahiri Y, Sampalis J, Brutus JP, Harris PG, Nikolis A. Wound healing assessment: does the ideal methodology for a research setting exist? Ann Plast Surg. 2011;67 (2):193-200. DOI: 10.1097/SAP.0b013e3181f3e0e8 https://doi.org/10.1097/SAP.0b013e3181f3... ⁾	2011	To identify existing methodologies available for wound healing assessment in clinical and research settings.	At the moment of the study, no ideal methodology was found.
Scotton⁽³⁸38. Scotton MF, Miot HA, Fernandes Abbade LP. Factors that influence healing of chronic venous leg ulcers: a retrospective cohort. An Bras Dermatol [Internet]. 2014 [cited 2015 May 15];89(3):414-22. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4056698/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾	2014	To identify clinical and therapeutic factors that influence healing of venous ulcers.	Longstanding ulcer, infection, lack of compression and longer use of antibiotics.
Beckman⁽³⁹39. Beeckman D, Van Lancker A, Van Hecke A, Verhaeghe S. A systematic review and meta-analysis of incontinence-associated dermatitis, incontinence, and moisture as risk factors for pressure ulcer development. Res Nurs Health. 2014;37(3):204-18.⁾	2014	To identify the association between incontinence-associated dermatitis, its most important etiologic factors, and PUs.	There was an association between incontinence, its etiologic factors, and PUs.

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E-mail: reeusp@usp.br

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[1] Corresponding autor: María Jesús Samaniego Ruiz, Universidad Católica de Valencia San Vicente Mártir, Escuela de Doctorado 65. 46008 – Valencia, España mariaje88@gmail.com