Validity of instruments used in nursing care for people
					with skin lesions

Content validation study comprised of two stages: the first was the development of the instruments, beginning with a literature review; the second, content validation by means of an evaluation conducted by 30 judges/experts. For analysis, the Kappa coefficient ≥ 0.61 and content validity index ≥ 0.75 were adopted.

Results

The judges presented nine suggestions regarding the instrument’s categories. All items of the ^{questionnaire} Questionnaire 1 PERSONAL IDENTIFICATION AND TRAINING/PROFESSIONAL QUALIFICATION 1.1 Age __________ years 1.2 Sex ( ) male ( ) female 1.3 Undergraduate disciplines in which you had access to the content (theory and practice) on wounds 1.4 Conducted further studies on content about wounds in addition to what was taught in course subjects ( ) No ( ) Yes 1.5 Opportunity to provide care to people with wound ( ) No ( ) In the subjects of the course ( ) At work ( ) In field practice ( ) Others _____________ 1.6 Observed the care of patients with wounds ( ) No ( ) In the subjects of the course ( ) At work ( ) In field practice ( ) Others _____________ 1.7 Participated in extracurricular courses or training on wounds ( ) No ( ) Theoretical ( ) Practical ( ) Theoretical-practical 1.8 Hourly load of training or course ________________ hours 2 KNOWLEDGE ABOUT NURSING CARE FOR PATIENTS WITH SKIN LESIONS Mark with an “X” the response that best answers the questions below: 2.1 What actions should be taken in the evaluation stage of a patient with skin lesion? 1.Conduct Interview (anamnesis) and physical examination. 2.Identify risk factors and check vital signs. 3.Evaluate the lesion and check for signs and symptoms of infection. 4.Identify the need for and provide additional exams. 5.ALL OF THE ABOVE. 2.2 Which aspects should be considered when evaluating the characteristics of the skin lesion? 1.Type and duration of lesion. 2.Characteristics of the bed and edges of the lesion. 3.Presence of odor, appearance and volume of exudate. 4.Location, depth and width of lesion. 5.ALL OF THE ABOVE. 2.3 Which signs of infection should be considered when evaluating the characteristics of the skin lesion? 1.Cool skin around the lesion, pain, exudate. 2.Necrosis, edema, exudate. 3.PAIN, ERYTHEMA, EDEMA AND HEAT, INCREASED AND PURULENT EXUDATE, ODOR. 4.Bleeding, pain, cold skin around the lesion. 5.Necrosis, pain, edema. 2.4 Which aspects should be considered when choosing the dressing to be applied onto the skin lesion? 1.Time of evolution of the lesion, presence of infection on the lesion. 2.Lesion location and type of skin lesion. 3.Depth of the lesion, presence of pain. 4.Length of the lesion, presence of pain. 5.ALL OF THE ABOVE. 2.5 During care of the wound and surrounding skin, what is the adequate procedure to perform when applying the dressing? 1.Change the cover used in treatment without cleaning the lesion, using clean dressing technique for all types of lesions. 2.CLEAN THE LESION WITH 0.9% SALINE SOLUTION PRIOR TO CHANGING THE DRESSING. 3.Remove previous dressing with 70% alcohol or ether, clean the lesion with 0.9% saline solution, and place the cover used in the treatment. 4.Change the cover and then clean the lesion. 5.Clean open lesions with antiseptic solution, leaving uncovered. 2.6 In the initial and subsequent evaluation of the skin lesion, the nurse should be aware of the wound characteristics that indicate the need to perform debridement. What are these characteristics? 1.PRESENCE OF SLOUGH, FOREIGN BODIES, NECROSIS, PURULENCE, LOCAL INFECTION. 2.Cavity ulcers with nerve exposure. 3.Ulcer on terminally-ill patient. 4.Ulcer on lower limbs with presence of granulation tissue. 5.Ulcer on lower limbs in process of epithelialization. 2.7 When recommending the coverage to be used in the treatment of the lesion, what should the nurse consider? 1.KNOW THE RECOMMENDATION, CONTRAINDICATION, CHANGING PERIOD, COST AND BENEFIT OF THE COVER IN RELATION TO THE CHARACTERISTICS OF THE LESION TO BE TREATED. 2.Choose any cover considering the type of lesion. 3.Recommend the cover to be used in the treatment of the lesion considering only the stage in the healing process. 4.Indicate the cover that is appropriate for the treatment of all kinds of lesion. 5.All of the above. 2.8 Whattcts are used in the topical treatment of skin lesions? 1.Chlorhexidine, calcium alginate. 2.PAPAIN, HYDROGEL. 3.Activated charcoal, silver sulfadiazine. 4.Semi-permeable film, essential fatty acids. 5.Povidone-iodine, calcium alginate. 2.8 What guidelines should be provided to patients with skin lesions and their relative/caregiver for continuing care? 1.Personal hygiene, nutrition, risk factors for the development and exacerbation of skin lesions. 2.Factors that interfere with the healing process, and self-care of the dressing. 3.Periodicity of application of the dressing, encouraging self-care and the performance of activities of daily living. 4.Problems in wound healing and conduct adopted and implemented in the treatment. 5.ALL THE ANSWERS CONTAIN IMPORTANT DIRECTIONS FOR PATIENTS WITH SKIN LESIONS AND THEIR FAMILY MEMBERS AND CAREGIVERS. 2.10 When completing the record and documentation of the care process for a patient with lesion, what should be done? 1.RECORD THE EVALUATION OF THE PATIENT WITH LESION, FROM THE INITIAL EVALUATION OF THE LESION AND ITS FEATURES THROUGHOUT TREATMENT, THE DIRECTIONS PROVIDED TO THE PATIENT AND THEIR FAMILY MEMBER/CAREGIVER. 2.Record results of laboratory tests and referrals to other health professionals. 3.Document evolution of lesion throughout treatment and preventive care. 4.Record the initial clinical evaluation of the patient with skin lesion. 5.Record the initial evaluation of the lesion and its features throughout the treatment and the observation script reached acceptable rates of content validity and concordance. Some categories attained scores above the given value, confirming the validity of the content.

Conclusion

The instruments showed satisfactory content validity rates, and can be used to measure the skills and knowledge of nursing care provided to people with skin lesions.

Nursing assessment; Nursing care; Validation studies; Wound healing; Skin/injuries

Category of instrument	Suggestions of judges (n)	Acceptance	Justification
Initial observations	Uses accessible language when addressing the person with lesion⁽¹1 . Waidman MA, Rocha SC, Correa JL, Brischiliari A, Marcon SS. [Daily routines for individuals with a chronic wound and their mental health]. Texto & Contexto Enferm. 2011; 20(4):691-9. Portuguese.⁾	Yes	Verbal communication in a language that is familiar to the patient is important so that he or she can understand the information provided to them, enabling the fulfillment of the delegated actions to ensure successful treatment⁽⁷7 . Morais GS, Costa SF, Fontes WD, Carneiro AD. [Communication as a basic instrument in providing humanized nursing care for the hospitalized patient]. Acta Paul Enferm. 2009; 22(3):323-7. Portuguese.⁾
Assessment of the person and skin lesion	Combines the items “Identify risk factors” and “Perform patient history”⁽¹1 . Waidman MA, Rocha SC, Correa JL, Brischiliari A, Marcon SS. [Daily routines for individuals with a chronic wound and their mental health]. Texto & Contexto Enferm. 2011; 20(4):691-9. Portuguese.⁾	No	In the constitution of care guidelines for people with skin lesions, the identification of risk factors appears as a separate item of the patient history⁽⁸8 . Dantas DV, Dantas RA, Costa IK, Torres GV. [Assistance protocol for venous ulcers patients: validation of contents]. Rev RENE. 2013;14(3):588-99. Portuguese.⁾
	Includes directed physical exam⁽⁵5 . Fonseca R, Silva P, Silva R. Acordo inter-juízes: o caso do coeficiente kappa. Lab Psicologia. 2007; 5(1):81-90.⁾	No	Authors refer to the performance of a complete and detailed physical examination of the person with skin lesion^(8.9)
	When evaluating the lesion, specifies the volume, depth and width measurements⁽³3 . Bittencourt HR, Creutzberg M, Rodrigues AC, Casartelli AO, Freitas AL. [Development and validation of an instrument for evaluating courses in higher education]. Est Aval Educ. 201;22(48):91-114. Portuguese.⁾	Yes	The measurements will be specified and standardized to facilitate the implementation of the instrument
Care of the wound and surrounding skin	Does not describe the saline jet stream technique to clean the lesion⁽¹1 . Waidman MA, Rocha SC, Correa JL, Brischiliari A, Marcon SS. [Daily routines for individuals with a chronic wound and their mental health]. Texto & Contexto Enferm. 2011; 20(4):691-9. Portuguese.⁾	No	Technique described in literature⁽¹⁰10 . Santos AA, Medeiros AB, Soares MJ, Costa MM. [Nursing students’ knowledge of wound evaluation and treatment]. Rev Enferm UERJ. 2010; 18(4):547-52. Portuguese.^,¹¹11 . Ferreira AM, Andrade D. [Integrative review of the clean and sterile technique: agreement and disagreement in the execution of dressing]. Acta Paul Enferm. 2008; 21(1):117-21. Portuguese.⁾
Care of the wound and surrounding skin	When applying the dressing, divides the item into clean and sterile techniques⁽³3 . Bittencourt HR, Creutzberg M, Rodrigues AC, Casartelli AO, Freitas AL. [Development and validation of an instrument for evaluating courses in higher education]. Est Aval Educ. 201;22(48):91-114. Portuguese.⁾	No	We opted for the sterile technique, since the instrument will be collected in hospitals and health care units. In the environment of health care services, sterile technique should be used⁽¹⁰10 . Santos AA, Medeiros AB, Soares MJ, Costa MM. [Nursing students’ knowledge of wound evaluation and treatment]. Rev Enferm UERJ. 2010; 18(4):547-52. Portuguese.⁾
Follow-up and guidance to people with skin lesions and their relative/caregiver	Includes nutrition guidance in health education actions for people with skin lesions⁽¹1 . Waidman MA, Rocha SC, Correa JL, Brischiliari A, Marcon SS. [Daily routines for individuals with a chronic wound and their mental health]. Texto & Contexto Enferm. 2011; 20(4):691-9. Portuguese.⁾	Yes	The guidelines should include the benefits of eating certain foods that are important to health⁽¹²12 . Alcoforado CL, Espirito Santo FH. [Knowledge and practices in nursing care to clients with wounds: the case of the city of Cruzeiro do Sul - Acre – Brazil]. REME – Rev Min Enferm. 2012;16(1):11-7. Portuguese.⁾
Records and documentation	Makes a record of the use of popular practices⁽¹1 . Waidman MA, Rocha SC, Correa JL, Brischiliari A, Marcon SS. [Daily routines for individuals with a chronic wound and their mental health]. Texto & Contexto Enferm. 2011; 20(4):691-9. Portuguese.⁾	Yes	There are several popular therapies that are used in wound care⁽¹²12 . Alcoforado CL, Espirito Santo FH. [Knowledge and practices in nursing care to clients with wounds: the case of the city of Cruzeiro do Sul - Acre – Brazil]. REME – Rev Min Enferm. 2012;16(1):11-7. Portuguese.⁾
Final observations	In the item relating to organization of the environment, provides details regarding the procedures used to organize the environment⁽⁵5 . Fonseca R, Silva P, Silva R. Acordo inter-juízes: o caso do coeficiente kappa. Lab Psicologia. 2007; 5(1):81-90.⁾	Yes	The details of the procedures involved in organization of the environment, after treatment of a person with skin lesion, standardizes and facilitates application of the instrument

Categories comprising the checklist	Concordance analysis
Categories comprising the checklist	Kappa	CVI
Initial observations
Initial Care	0.76	0.87
Sanitizes hands	0.73	0.84
Assessment of the person and skin lesion
Medical history taking	0.78	0.87
Identifies risk factors	0.74	0.85
Performs physical examination	0.73	0.84
Checks vital signs	0.78	0.88
Assesses the presence of pain	0.77	0.87
Evaluates the skin lesion	0.72	0.83
Identifies signs of infection	0.76	0.85
Identifies the need for, and provides exams	0.82	0.90
Care of lesion and surrounding skin
Cleans wound	0.65	0.78
Applies dressing	0.66	0.78
Assesses the need for debridement	0.79	0.87
Recommends coverage	0.81	0.89
Referral and guidance to the person with skin lesion, relative/caregiver
Develops educational activities	0.85	0.91
Identifies and provides referral	0.84	0.91
Record and documentation
Records clinical evaluation	0.81	0.89
Records lesion evaluation	0.82	0.89
Final observations
Organizes the environment	0.74	0.85
Sanitizes hands after care	0.80	0.88

Categories comprising the checklist	Agreement analysis
Categories comprising the checklist	Kappa	CVI
Q1. What actions should be taken in the evaluation stage of a person with skin lesion?	0.76	0.86
Q2. Which aspects should be considered when evaluating the characteristics of the skin lesion?	0.81	0.89
Q3. Which signs of infection should be considered when evaluating the characteristics of the skin lesion?	0.82	0.89
Q4. Which aspects should be considered when choosing the dressing to be applied onto the skin lesion?	0.71	0.81
Q5. During the care of the wound and surrounding skin, what is the adequate procedure to perform during application of the dressing?	0.78	0.87
Q6. In the initial and subsequent evaluation of the skin lesion, the nurse should be aware of the wound characteristics that indicate the need to perform debridement. What are these characteristics?	0.83	0.90
Q7. When recommending the coverage to be used in the treatment of the lesion, what should the nurse consider?	0.86	0.92
Q8. What debriding action products are used in the topical treatment of skin lesions?	0.76	0.86
Q9. What guidelines should be provided to the person with skin lesions and their relative/caregiver for continuing care?	0.82	0.90
Q10. When completing the record and documentation of the care process for a person with lesion, what should be done?	0.86	0.92

Escola Paulista de Enfermagem, Universidade Federal de São Paulo R. Napoleão de Barros, 754, 04024-002 São Paulo - SP/Brasil, Tel./Fax: (55 11) 5576 4430 - São Paulo - SP - Brazil
E-mail: actapaulista@unifesp.br

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[1] Corresponding author Roberta Kaliny de Souza Costa André Sales street, 667, Caicó, RN, Brazil. Zip Code: 59300-000 robertaksc@bol.com.br