I NTER RATER RELI ABI LI TY OF PRESSURE ULCER SCALE FOR HEALI NG ( PUSH) I N
PATI ENTS W I TH CHRONI C LEG ULCERS
Vera Lúcia Conceição de Gouveia Sant os1 Danielle Sellm er2 Marley Maciel Elias Massulo3
San t os VLCG, Sellm er D, Massu lo MME. I n t er r at er r eliabilit y of Pr essu r e Ulcer Scale for Healin g ( PUSH) in pat ient s w it h chr onic leg ulcer s. Rev Lat ino- am Enfer m agem 2007 m aio- j unho; 15( 3) : 391- 6.
This st udy aim ed t o evaluat e t he int er rat er reliabilit y of t he Pressure Ulcer Scale for Healing ( PUSH) , in its version adapted to the Portuguese language, in patients with chronic leg ulcers. Kappa index was used for t he analysis. Aft er accom plishing et hical issues, 41 pat ient s wit h ulcers were exam ined. A t ot al of 49% of t he ulcers were locat ed in t he right leg and 36% of t hem were venous ulcers. The Kappa indices ( 0.97 t o 1.00) obt ained in t he com parison bet ween t he observat ions of t he clinical nurses and t he st om al t herapist s for all sub- scales and for t ot al score, confirm ed t he t ool int er rat er reliabilit y, wit h st at ist ical significance ( p< 0.001) . The PUSH inst rum ent , in it s Port uguese adapt ed version, show ed t o be reliable t o t he use in pat ient s w it h chronic leg ulcers. Furt her st udies should be conduct ed t o evaluat e it s prospect ive perform ance.
DESCRI PTORS: wound healing; nursing assessm ent ; reproducibilit y of result s
CONFI ABI LI DAD I NTER-OBSERVADORES DEL PRESSURE ULCER SCALE FOR HEALI NG
( PUSH) EN PACI ENTES CON ÚLCERAS CRÓNI CAS EN LA PI ERNA
El obj et iv o del est údio fue pr obar la confiabilidad int er - obser v ador es del Pr essur e Ulcer Scale for Healing ( PUSH) , en su versión adapt ada al port ugués, en pacient es con úlceras crónicas en la pierna. Para el análisis de concordancia se ut ilizó el I ndice Kappa. Post erior a la aprobación del Com it é de Ét ica, 41 pacient es con úlcer a fuer on ex am inados, siendo que 49% de las úlcer as se localizar on a la der echa y 36% er an de etiología venosa. Los indices Kappa obtenidos ( 0,97 a 1,00) , con un nivel significativo de p< 0,001, confirm aron la confiabilidad de los int er- observadores, al obt enerse un nivel de concordancia m uy bueno ent re el t ot al de las obser v aciones r ealizadas por enfer m er os clínicos y especialist as en est om at ología ( pat r ón- or o) , dichos valores obtenidos tanto para todas las sub escalas de PUSH com o para el puntaj e total. Los resultados perm iten concluir que el PUSH, en su versión adapt ada para el port ugués, m ost ró confiabilidad para ser ut ilizado en pacientes con úlceras crónicas en m iem bros inferiores, debiendo am pliarse el estudio para evaluar su desem peño pr ospect iv o.
DESCRI PTORES: cicat rización de heridas; evaluación en enferm ería; reproducción de t est
CONFI ABI LI DADE I NTEROBSERVADORES DO PRESSURE ULCER SCALE FOR HEALI NG
( PUSH) , EM PACI ENTES COM ÚLCERAS CRÔNI CAS DE PERNA
Test ar a confiabilidade int erobservadores do Pressure Ulcer Scale for Healing ( PUSH) , em sua versão adapt ada para o port uguês, em pacient es com úlceras crônicas de perna foi o obj et ivo dest e est udo. Para a análise de concor dância, ut ilizou- se o índice Kappa. Após apr ov ação pelo Com it ê de Ét ica, pacient es com úlceras ( 41) úlceras foram exam inados, sendo que 49% das úlceras localizavam - se à direit a e 36% eram de et iologia venosa. Os índices Kappa obt idos ( 0,97 a 1,00) , com significância est at íst ica ( p< 0,001) , rat ificaram a confiabilidade int er obser vador es, ao ser obt ida concor dância de m uit o boa a t ot al ent r e as obser vações de enfer m eir os clínicos e especialist as em est om at er apia ( padr ão- our o) , par a t odas as subescalas do PUSH, com o para o escore t ot al. Esses result ados perm it em concluir que o PUSH, em sua versão adapt ada para o port uguês, m ost rou confiabilidade para ut ilização em pacient es com úlceras crônicas de m em bros inferiores, devendo- se am pliar o est udo para avaliação de seu desem penho prospect ivo.
DESCRI TORES: cicat rização de feridas; avaliação em enferm agem ; reprodut ibilidade dos t est es
1
RN, Specialist in St om al Therapy, Associat ed Professor Universit y of São Paulo College of Nursing, Brazil, e- m ail: [email protected]; 2 RN, specialist in St om al Therapy, Assist ent in t he St om al Therapy course of t he Pont ifícia Cat holic Universit y of Paraná, Brazil; 3 RN, Specialist in St om al Therapy. I n m em orian
I NTRODUCTI ON
H
e a l t h p r o f e ssi o n a l s h a v e t a k e n sp e ci a l in t er est in w ou n d car e. I n t h is con t ex t , t h e n u r ses’ role st ands out , who have searched for new knowledge t o base t heir pr act ice.I t is known t hat chronic leg ulcers are part of a s e t o f c h r o n i c d i s e a s e s , w h o s e i n c i d e n c e h a s gradually increased all over t he w orld. Regarding t he n egat iv e im pact on pat ien t s’ qu alit y of lif e, ch r on ic ulcers in t he inferior lim bs represent t he t ypical chronic inj ury problem because t hey cause different levels of pain, affect m obilit y and are alm ost always recurrent(
1-2 )
. Th er ef or e, it is n ecessar y t o sy st em ize car e f or t h e se p a t i e n t s, i n w h i ch w o u n d a sse ssm e n t i s a det er m inant fact or for adequat e t herapy.
The wound assessm ent process is of essent ial im port ance for t he developm ent of a good t herapeut ic plan. Appr opr iat e t opical car e and assessm ent of t he lesion ar e on ly possible w h en t h e obser v at ion s an d r esult s of int er v ent ions ar e r ecor ded.
I n a r e t r o s p e c t i v e c o h o r t s t u d y o f 2 6 0 pat ient s, t he aut hor s( 3) dem onst r at ed t hat t he init ial area of t he ulcer, t he presence of fibrin and t he excess o f e x u d a t e w e r e s o m e o f t h e r i s k f a c t o r s com pr om isin g t h e h ealin g of ch r on ic v en ou s u lcer s. Ot her aut hors( 4- 5) verified t hat chronic leg wound area r edu ct ion per cen t ages, r espect iv ely in t h e f ir st t w o a n d f o u r w e e k s o f t r e a t m e n t , w e r e s i g n i f i c a n t pr edict iv e fact or s of healing t im e.
I n a p r e v i o u s s t u d y , t h e a u t h o r s( 6 ) per f or m ed t h e t r an scu lt u r al adapt at ion of PUSH f or t h e Po r t u g u e s e l a n g u a g e , a c c o r d i n g t o a m e t h o d o l o g y r e c o m m e n d e d i n i n t e r n a t i o n a l l i t er at u r e, at t est i n g i n t er r at er co n v er g en t v al i d i t y a n d r e l i a b i l i t y o f t h e a l r e a d y t r a n sl a t e d v e r si o n . Th e r esu l t s o b t a i n ed f o r t h e Ka p p a i n d i ces ( 0 . 9 0 t o 1 . 0 ) b e t w e e n t h e o b se r v a t i o n s o f n u r se s a n d st om al sp ecialist s ( g old st an d ar d ) f or all su b scales a n d t h e t o t a l sco r e o f t h e sca l e , a s w e l l a s t h e e x i st e n ce o f a st a t i st i ca l l y si g n i f i ca n t ( p < 0 . 0 0 1 ) p osit iv e cor r elat ion b et w een t h e ob ser v at ion s w it h r egar d t o t h e st agin g of u lcer s an d t h e t ot al scor e o f t h e s c a l e a t t e s t e d r e s p e c t i v e l y , b o t h m e a s u r e m e n t p r o p e r t i e s , c o n f i r m i n g t h e f u t u r e u t i l i zat i o n o f t h e ad ap t ed v er si o n o f t h e PUSH i n o u r a r e a . T h e a v a i l a b i l i t y o f t h i s s c a l e i n o u r lan gu age, t h e ease an d f easibilit y of it s applicat ion
– a l so co n f i r m e d i n t h e st u d y( 6 ) – a s w e l l a s i t s com p on en t f act or s or su b scales (lengt h and w idt h, ex udat e am ount and t issue t y pe in t he w ound bed) – c o m m o n a n d e s s e n t i a l t o a s s e s s t h e h e a l i n g p r o c e s s o f a n y c h r o n i c w o u n d – m o t i v a t e d t h e r ealizat ion of t h is r esear ch t o t est it s ap p licab ilit y in an ot h er k in d of lesion : ch r on ic u lcer s of in f er ior lim b s. I n 2 0 0 4 , w h en t h e abst r act of t h is st u dy w as p u b l i sh e d * , d u r i n g t h e 1 5t h Bi e n n i a l Co n g r e ss o f t h e Wor ld Cou n cil of En t er ost om al Th er ap ist s, t h is w a s t h e f i r st st u d y w i t h t h i s o b j e ct i v e , e v e n i n i n t er n a t i o n a l l i t er a t u r e. Th i s st u d y a i m ed t o t est t h e in t er r at er r eliabilit y of t h e PUSH in it s adapt ed v er si o n f o r t h e Po r t u g u ese l an g u ag e.
PRESSURE ULCER SCALE FOR HEALI N G
( PUSH)
Th e i n st r u m e n t Pr essu r e Ul cer Scal e f o r Healing ( PUSH) , used for t he evaluat ion of t he healing process of PU and int ervent ion result s, was developed an d v alidat ed, in 1 9 9 6 , b y t h e PUSH Task For ce at NPUAP( 7- 8). The PUSH inv olv es t hr ee par am et er s and su bscales( 7 ):
- surface area of t he wound, m easur es t he gr eat est lengt h ( head t o t oe) and t he gr eat est w idt h ( side t o side) , in squar e cent im et er s. Aft er t he m ult iplicat ion of t h e t w o m easu r es in or der t o obt ain t h e su r face area of t he wound, values t hat varied bet ween 0 and > 2 4 cm2 an d scor es t h at r an ged fr om 0 t o 1 0 ar e found, accor ding t o t he obt ained ar ea;
- ex udat e am ount p r esen t in t h e w ou n d , assessed af t er r em ov al of t h e d r essin g an d b ef or e ap p ly in g a n y t o p i ca l a g en t . I t i s cl a ssi f i ed a s n on e, lig h t , m oder at e an d heav y, w h ich cor r esp on d s t o scor es from 0 ( none) t o 3 ( heavy) ; and
- tissue type of t he wound bed, defined as t he t ypes of t issue prevalent in t his region, specified as: necrotic t issu e ( e sch a r ) , b l a ck , b r o w n , o r t a n t i ssu e t h a t adher es fir m ly t o t he w ound bed or ulcer edges and m ay be eit her firm er or soft er t han surrounding skin;
slough, yellow or whit e t issue t hat adheres t o t he ulcer b e d i n st r i n g s o r t h i ck cl u m p s, o r i s m u ci n o u s;
gr anulat ion t issue, p in k or b eef y r ed t issu e w it h a shiny, m oist , gr anular appearance; epit helial t issue,
for super ficial ulcer s, new pink or shiny t issue ( sk in) t h at g r ow s in f r om t h e ed g es or as islan d s on t h e
*
ulcer surface and closed/ resurfaced wound, t he wound is com plet ely cov er ed w it h epit helium . These t issues cor r espond t o scor es 0 ( closed w ound) , 1 ( epit helial t i ssu e) , 2 ( g r a n u l a t i o n t i ssu e) , 3 ( sl o u g h ) a n d 4 ( necr ot ic t issue) .
When added up, t he subscale scores generat e t he t ot al score, which can range from 0 t o 17. Higher scores indicat e worse ulcer condit ions and dim inishing scor es in d icat e im p r ov em en t in t h e w ou n d h ealin g p r o c e s s . Th e r e f o r e , b y m e a s u r i n g o n l y t h r e e v a r i a b l es, t h e i n st r u m en t PUSH g en er a t es sco r es w h o se m a g n i t u d e a n d d i r e ct i o n ca n d e scr i b e t h e condit ion and evolut ion of wounds( 7). Besides t he t hree p a r a m e t e r s, t h e i n st r u m e n t co n t a i n s o p e r a t i o n a l definit ions for each, a t able where t he scores of each param et er and t he t ot al score are regist ered according t o t h e d at e. Th er e is also a ch ar t t o v isu alize t h e evolut ion of t he t ot al scores and an inst ruct ion sheet for t he evaluat or.
METHOD
This m et hodological st udy aim ed t o ev aluat e t he int errat er reliabilit y of t he PUSH scale, applied t o people w it h chr onic leg ulcer s.
Re l i a b i l i t y i s d e f i n e d a s t h e d e g r e e o f coherence and precision by which a cert ain inst rum ent m easur es t he at t r ibut e it is pr oposed t o m easur e( 9).
I n t e r r a t e r r e l i a b i l i t y a n a l y z e s t h e d e g r e e o f con cor dan ce or t h e con sist en ce of t h e per for m ance
o f t w o o r m o r e o b ser v er s i n r eco r d i n g t h e sa m e r esp on ses at t h e sam e t im e( 9 ). I n t h is st u d y, t h is p r o p er t y w a s v er i f i ed b y co m p a r i n g o b ser v a t i o n s m ade by st om al t h er apy specialist n u r ses ( ST) an d clinical nur ses, w hen using PUSH sim ult aneously and in d ep en d en t ly.
PUSH w as clinically applied at t he out pat ient unit s of five public hospit als in t he Cit y of São Paulo, t o ad u lt p at ien t s w it h ch r on ic leg u lcer s ( v en ou s, ar t er ial, m ix ed, diabet ic an d ot h er s) , in depen den t ly o f t h e co n d i t i o n s t h e y w e r e i n a n d / o r t r e a t m e n t pr ot ocols u sed.
B e f o r e s t a r t i n g t h e d a t a c o l l e c t i o n , t h e r esear ch pr oj ect w as appr ov ed by t he Rev iew Boar d of t he Univ er sit y of São Paulo School of Nur sing as well as by t he hospit al services responsibles. The dat a collect ion w as car r ied out by four clinical nur ses and t h r ee STs – r espon sible f or t h e ser v ices w h er e t h e
d at a w er e collect ed an d su p er v isor s of t h e n u r ses’
clinical pract ice, during specialized educat ion in st om al t h er ap y. Th ey com pr ised, r espect iv ely, t w o gr ou ps: n u r se s a n d st o m a l t h e r a p y sp e ci a l i st s ( ST) . Th e clin ical n u r ses r eceiv ed p r ev iou s t ech n ical su p p or t , r elat ed t o t he pr ev ent ion, ev aluat ion and t opical and sy st em i c t r eat m en t of acu t e an d ch r on i c w ou n d s, du r in g t h e Specializat ion Cou r se in St om al Th er apy Nu r sin g ; t h e STs’ ob ser v at ion s w er e con sid er ed as t he gold st andar d for st at ist ical com par ison.
All adult pat ient s wit h chronic leg ulcers, who com prised t he convenience sam ple in t his st udy, were p r esen t a t t h e o u t p a t i en t cl i n i cs d u r i n g t h e d a t a collect ion period and chosen by t he STs in t he rout ine care process. Alt hough it was a convenient sam ple, a m inim um of 30 lesions was est ablished for t he viabilit y of t h e st u dy – t en obser v at ion s f or each ev alu at ed p a r a m e t e r ( t h r e e s u b s c a l e s ) – b a s e d o n t h e d e t e r m i n a t i o n r e co m m e n d e d i n t h e t r a n scu l t u r a l adapt at ion an d v alidat ion m et h od of PUSH, u sed in t h e pr ev iou s st u dy( 6 ). Wh en con t act ed, t h e pat ien t s w e r e d u l y i n f o r m e d a b o u t t h e s t u d y g o a l s a n d pr ocedur es, follow ed by t he signing of t he fr ee and i n f o r m e d c o n s e n t t e r m , w h e n t h e y a c c e p t e d t o par t icipat e in t he st udy.
D at a w er e co l l ect ed d u r i n g t o p i cal w o u n d t r ea t m en t . Ea ch a ssessm en t w a s p er f o r m ed sim ult aneously and independent ly by t hree observers: one ST and t wo nurses, generat ing, at t he end, t hree assessm ent s of each lesion. First , t he pat ient ’s inferior lim bs were m eticulously exam ined, aim ing to identify the num ber and location of the chronic wounds. I n case of p at ien t s w it h m or e t h an on e u lcer, each u lcer w as considered as an independent case. After this identification, t he wound dressing was rem oved, proceeding wit h t he visual exam , and the am ount of exudate and length and w id t h of t h e w ou n d w er e ev alu at ed an d r ecor d ed , according to the procedures described in the instrum ent. Aft er t he cleansing t he wound wit h 0.9% PS, t he t hird inst rum ent it em , t hat is, t he t issue t ype present in t he wound bed was evaluated.
For dat a collect ion, t he PUSH, in it s adapt ed v er si o n f o r t h e Po r t u g u ese l a n g u a g e( 6 ), w a s o n l y m odified by r eplacing t he t er m “ pr essur e ulcer s” by “ chr onic leg ulcer s”, w henev er possible. I n addit ion, t w o q u e st i o n s w e r e i n cl u d e d a b o u t t h e k i n d a n d locat ion of t he w ound.
Dat a An aly sis
ulcer, w er e subm it t ed t o descr ipt ive analy sis, aim ing
t o charact erize t he assessed ulcers. To t est int errat er r eliab ilit y ( ST an d Nu r se 1 an d 2 ) , t h e Kap p a (k) ag r eem en t m easu r e w as u sed . For t h is st u d y, t h e
s a m e c a t e g o r i z a t i o n f o r K a p p a c o e f f i c i e n t s w a s adopt ed as used in t he previous st udy ( 6) : k = 1.0 as t ot al agr eem ent and 0.81 = k = 0.99 for v er y good a g r e e m e n t . Th e K a p p a c o e f f i c i e n t w a s a l w a y s
calculat ed in relat ion t o t he ST’s observat ion. P- value under 0.05 was used for st at ist ical significance. SPSS f o r W i n d o w s v e r s i o n 1 0 . 0 w a s u s e d f o r d a t a
p r ocessin g .
RESULTS
Fo r t y - o n e u l c e r s w e r e a n a l y z e d a n d
com prised t he st udy sam ple: 36% w ere vasculogenic o f v e n o u s o r i g i n , 1 5 % a r t e r i a l , 1 5 % m i x e d , 5 % diabet ic and 29% did not have a defined diagnosis. A t ot al of 49% of t he lesions were locat ed on t he right
infer ior lim b.
Nex t , t h e com par at iv e box - plot s ( Figu r es 1 t o 4) of t he subscores of t he t hree PUSH param et ers
ar e pr esent ed, besides t he t ot al scor e, for t he t hr ee ev al u at o r s – ST an d n u r ses 1 an d 2 – r el at ed t o in t er r at er r eliabilit y an aly ses. Th e r espect iv e Kappa an d p coef f icien t s ar e alw ay s p r esen t ed b elow t h e
f ig u r es.
Figure 1 – Com parat ive Box- plot of t he sub- scores of
t he lengt h x w idt h variable. São Paulo, 2003
Figure 1 shows t hat t he nurses present ed t ot al
a n d v er y g o o d a g r eem en t l ev el s, r esp ect i v el y, i n
relat ion t o t he observat ions m ade by t he ST ( p< 0.001) .
All obser v er s equ ally m easu r ed an av er age ar ea of 7.0± 2.7 cm2.
Figure 2 – Com parat ive box- plot of t he sub- scores of
t he exudat es am ount v ar iable. São Paulo, 2003
Fo r e x u d a t e a m o u n t ( Fi g u r e 2 ) , t o t a l
agreem ent am ong all observers’ answers was verified (k= 1,00 e p< 0,001) . Thus, t he m ean scor e obt ained for all w as 1.83± 0.70.
Figure 3 - Com parat ive box- plot of t he sub- scores of t he t issue t ype v ar iable. São Paulo, 2003
Figure 3 shows, again, st at ist ically significant ( p < 0 . 0 0 1 ) t o t a l a g r e e m e n t (k= 1 . 0 0 ) a m o n g a l l observers’ answers ( ST and nurses 1 and 2) , wit h an
av er age scor e of 3.20± 0.75 for all.
41 41
41 N =
C/L ENF.2 C/L ENF.1
C/L SUPER 12
10
8
6
4
2
0
Kappa ST x Nurse 1 = 1,00 (p<0,001) Kappa ST x Nurse 2 = 0,97 (p<0,001)
L/W SUPER L/W NURSE 1 L/W NURSE 2
Kappa ST x Nurse 1 = 1,00 (p<0,001) Kappa ST x Nurse 2 = 1,00 (p<0,001)
41 41
41 N =
E/A NURSE 2 E/A NURSE 1
E/A SUPER 3,5
3,0
2,5
2,0
1,5
1,0
,5
0,0
-,5
Kappa ST x Nurse 1 = 1,00 (p<0,001) Kappa ST x Nurse 2 = 1,00 (p<0,001)
4 1 41
41 N =
T/T NURSE 2 T/T NURSE 1
T/T SUPER 4,5
4,0
3,5
3,0
2,5
2,0
Figure 4 - Com parat ive box- plot of t he sub- scores of t he t ot al score v ar iable. São Paulo, 2003
Levels of t ot al and very good agreem ent were v er if ied b et w een t h e r esp on ses of Nu r se 1 an d ST an d Nu r se 2 an d ST, r espect iv ely, bot h st at ist ically sign ifican t ( p< 0 . 0 0 1 ) . Nu r se 1 an d ST an d n u r se 2 at t r ibu t ed av er age scor es of 1 2 . 0 ± 3 . 2 e 1 2 . 0 ± 3 . 3 , r esp ect iv ely.
DI SCUSSI ON
Due t o t he need for a pr ecise and pr act ical m et hod of m onit oring t he clinical evolut ion and healing o f p r e s s u r e u l c e r s , t h e Na t i o n a l Pr e ssu r e Ul ce r Advisory Panel ( NPUAP) developed t he Pressure Ulcer
Sca l e f o r He a l i n g ( PU S H )( 7 - 8 , 1 0 ) , w h o s e m a i n ch a r a ct e r i st i c i s i t s e a sy a p p l i ca t i o n( 1 1 ). An o t h e r aut hor( 12) considers t hat t he great est ut ilit y of PUSH is t he assessm ent of w ound healing ov er a long per iod o f t i m e, w h i ch p er m i t s m o n i t o r i n g g l o b a l h ea l i n g r esult s in a w ound t r eat m ent pr ogr am .
The ease and feasibilit y of it s applicat ion, as w ell as it s com ponent fact or s, pr esent in t he healing assessm ent of any chr onic w ound, m ade t he aut hor s of t his proj ect adapt and validat e PUSH t o t he Brazilian cult ure and expand t he st udy of it s applicat ion t o ot her k inds of chr onic w ounds, such as leg inj ur ies.
S i n c e PUS H i s a c l i n i c a l a s s e s s m e n t i n st r u m en t an d , t h er ef o r e, d ep en d s o n t h e d i r ect obser v at ion and r ecor ding of v ar iables, at t he least , it n eeds t o be t est ed t o v er ify if t h er e is in t er r at er reliabilit y( 9), which was confirm ed in t his research. The h ig h lev els of – t ot al an d v er y g ood – ag r eem en t bet w een t h e an sw er s of t h e n u r ses an d t h e st om al
specialist , all wit h st at ist ical significance of 1% , rat ified t he int errat er reliabilit y of t he inst rum ent for use wit h t his k ind of chr onic lesion as w ell, w hich is differ ent fr om t he pr essur e et iology.
I n ot her previous st udies( 6,10,12- 13), t he aut hors had alr eady t est ed t he sensibilit y and v alidit y of t he PUSH, t h o u g h a l w a y s a p p l i ed t o p r essu r e u l cer s. S o m e o f t h e s e a u t h o r s( 1 0 ) c o n f i r m e d t h a t t h e i n st r u m en t m eet s t h e r esea r ch er s’ r eq u i r em en t s, a l t h o u g h i n c l u d i n g o n l y t h r e e v a r i a b l e s , a n d recom m end t hat it s analysis m ust occur prospect ively, in a m inim um period of t w o w eeks.
Mor e r ecen t ly, on ly on e p r osp ect iv e st u d y w a s f o u n d( 1 4 ) a b o u t t h e u se o f PUSH i n v e n o u s ch r on ic u lcer s. Ou t pat ien t s w it h 2 7 lesion s, f ollow ed b y t w o s p e c i a l i s t n u r s e s , o b t a i n e d i m p o r t a n t ch an g es in t h e t ot al av er ag e scor es of t h e scale: f r o m 1 2 , i n t h e i n i t i a l a sse ssm e n t , t o 9 a n d 8 , r e sp e ct i v e l y, a t t h e e n d o f t h e f i r st a n d se co n d m on t h s of f ollow - u p. A t ot al of 2 3 pat ien t s r each ed t o t a l h e a l i n g a f t e r t w o m o n t h s o f f o l l o w - u p . Th e au t h or s con clu d ed t h at t h e in st r u m en t r ev ealed t o b e ef f ect i v e f o r t h e ev a l u a t i o n o f ch r o n i c v en o u s u l ce r s – t h e m o st f r e q u e n t o n e s a m o n g ch r o n i c leg u lcer s, also in ou r r esear ch .
A sim ilar st u dy discu sses t h e adapt at ion of t he Pressure Sore Status Tool ( PSST) for t he evaluat ion of ch r on ic leg u lcer s. Wh en t est ed , t h e in st r u m en t t h a t o r i g i n a t e d f r o m i t – Ph o t o g r a p h i c W o u n d
Assessm ent Tool ( PWAT) – also obt ained a scor e of > 0.8 for int errat er reliabilit y, confirm ing t he possibilit y of it s fut ure use in ot her chronic ulcers( 15). Bot h st udies confir m som e aut hor s’ beliefs, w ho indicat e t he use of t he sam e inst r um ent s t o assess differ ent k ind of lesion s, pr ov ided t h at t h ey in clu de com m on in dices or v ar iables for analy sis.
Som e st udy lim it at ions should be indicat ed. Besides t he reduced num ber of cases, it m ust be t aken int o account t hat t he nur ses w ho par t icipat ed in t he s t u d y r e c e i v e d p r e v i o u s t h e o r e t i c a l i n s t r u c t i o n r egar ding car e of people w it h w ounds. Alt hough t his aspect is not est ablished by NPUAP as a requirem ent f or u sin g PUSH, t h e pr ev iou s in st r u ct ion m ay h av e fav or ed t h e good per for m an ce of t h e scale. On t h e ot her hand, t he lack of lit erat ure regarding t he use of PUSH t o a sse ss o t h e r k i n d s o f u l ce r s m a k e s t h e discussion of findings m or e difficult .
FI NAL CONSI DERATI ONS
I n t h i s st u d y, i n w h i ch t h e v er si on of t h e
Pr e ssu r e Sca l e f o r H e a l i n g ( PU S H ) a d a p t e d t o
Kappa ST x Nurse 1 = 1,00 (p<0,001) Kappa ST x Nurse 2 = 0,97 (p<0,001)
41 41
41 N =
Tot/Sc - NURSE 2 Tot/Sc –NURSE 1
Tot/Sc - SUPER 18
16
14
12
10
8
6
Po r t u g u e s e w a s u s e d , m o d i f y i n g o n l y t h e ex pr ession “ pr essu r e u lcer s” by “ ch r on ic leg u lcer s”, t h e i n t e r r a t e r r e l i a b i l i t y o f t h e i n s t r u m e n t w a s c o n f i r m e d b y t h e o b t a i n e d K a p p a c o e f f i c i e n t s , w h ich r an g ed f r om 0 . 9 7 t o 1 . 0 0 . Th at is, lev els of ag r eem en t b et w een t h e ob ser v at ion s m ad e b y t h e clin ical n u r ses an d st om al sp ecialist s r an g ed f r om v er y good t o t ot al f or all t h e su bscales an d f or t h e t ot al scor e of PUSH.
Since t he acr ony m PUSH r efer s t o pr essur e u l cer s, o n ce t h e u se o f t h i s i n st r u m en t h as b een confir m ed t o assess chr onic ulcer s, w e suggest t hat it s nam e be changed t o Chronic Ulcer Scale for Healing,
w hich w ould generat e t he acr ony m CUSH. How ev er, t h is ch an g e w ill n eed t h e ap p r ov al of NPUAP. Th e acr on y m an d t it le of t h e alr ead y ad ap t ed scale, in En g lish – as p r op osed in p r ev iou s st u d y( 6 ) – w er e m ai n t ai n ed d u e t o t h e n eed o f i t s r eco g n i t i o n , i n
i n t e r n a t i o n a l c o m m u n i c a t i o n , w i t h s t a n d a r d i z e d acr o n y m s.
We also r ecom m en d pr ospect iv e st u dies t o bet t er assess t he perform ance of t he scale, especially w it h r egar d t o t he analy sis of t he healing pr ocess – for w hich t his inst r um ent w as designed – in chr onic leg w ou n d s, as w ell as w it h n u r ses n ot p r ev iou sly t rained. We inform t hat prospect ive st udies t o evaluat e t he perform ance of PUSH, bot h in pressure ulcers and t hose of leg, ar e alr eady being concluded.
ACKNOW LEDGMENTS
To our fellow st om al specialist Selm a Barboza Perdom o, Karina Barduco Vassilieff, Leila Blanes, Maria das Graças Leit e, Elizabet e Capalbo Ferolla and Márcia Just ina Filippin for t heir collaborat ion in dat a collect ion.
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