Yaraların Değerlendirilmesi
Özet
Yaraların değerlendirilmesi etkili yara tedavisi ve bakımı için esastır. Yaraların değerlendirilmesi; yaralara iyileşmesine ilişkin temel bilgileri, uygun tedavi ve bakım hedeflerini belirlemeyi ve doğru pansuman seçimini sağlar. Yanlış değerlendirme, uygunsuz yara yönetimine yol açarak iyileşmenin gecikmesine ve ciddi komplikasyonlara neden olabilir. Yara tedavi ve bakımında bütüncül ve sistematik bir yaklaşım benimsenmelidir. Yara değerlendirmesi ilk ve devam eden değerlendirmeleri içermektedir. Akut yaralar her pansuman değişiminde, kronik yaralar ise genel olarak haftalık olarak değerlendirilmelidir. Yaraların değerlendirilmesinde doğruluğu kanıtlanmış değerlendirme araçları kullanılmalıdır. Yara değerlendirmesi yara yönetiminin merkezinde yer almalı ve yara bakım uygulamasının ayrılmaz bir parçası olarak ele alınmalıdır.
Referanslar
Grey, J. E., Enoch, S., & Harding, K. G. (2006). Wound assessment. BMJ, 332(7536), 285–288. doi:10.1136/bmj.332.7536.285
Greatrex-White S, Moxey H.Wound assessment tools and nurses’ needs: an evaluation study. Int Wound J 2015; 12:293–301. doi: 10.1111/iwj.12100
Benbow, M. (2016). Best practice in wound assessment. Nursing standard, 30(27).
Nichols, E. L. I. Z. A. B. E. T. H. (2016). Wound assessment part 2: exudate. Wound Essentials, 11(1), 36-41.
Öngel, K., Mergen, H. (2008). New wound dressing products under the light of literature. Turkish Journal of Surgery, 24(2):104-108.
Nagle, S. M., Stevens, K. A., & Wilbraham, S. C. (2018). Wound assessment.
Moura, M., Dowsett, C., Bain, K., & Bain, M. (2020). Advancing practice in holistic wound management: a consensus-based call to action. Wounds International, 11(4), 70-75.
Tan, P., Lim, J., & Moiemen, N. (2021). Imaging techniques used for wound healing assessment: A systematic review part 1 chronic wounds. European Burn Journal, 2(4), 194-214.
Nichols, E. (2015). Wound assessment part 1: How to measure a wound. Wound Essentials, 10(2), 51-5.
Savcı, A. Yara Değerlendirme ve TIME Yaklaşımı. Erişim: https://hmyo.ankara.edu.tr/wp-content/uploads/sites/438/2019/03/Yara-Tan%C4%B1lama-ve-T%C4%B0ME-yakla%C5%9F%C4%B1m%C4%B1.pdf
Toklu, A. S. Kronik Yarada Ölçme ve Değerlendirme. Ed: Topalan M, Aktaş Ş. Güncel Yönleriyle Kronik Yara. Aygül Ofset Matbaacılık San. Tic. Ltd. Şti.1. Baskı, Şubat, Ankara. 2010: 27-31.
Bowers, S., & Franco, E. (2020). Chronic wounds: evaluation and management. American family physician, 101(3), 159-166.
Asgarpour, H. Venöz Ayak Ülser Tedavisinde Güncel Yaklaşımlar. Süleyman Demirel Üniversitesi Sağlık Bilimleri Dergisi, 10(3), 333-339. https://doi.org/10.22312/sdusbed.560995
Öztaş, P. (2021). Yara iyileşmesi, bakımı ve tedavisi. Ankara Eğitim ve Araştırma Hastanesi Tıp Dergisi, 54(2), 341-351.
Eraydın, Ş., & Avşar, G. (2019). Diyabetik Ayak Ülserinde Fiziksel Muayene ve Hemşirelik Bakimi. Anadolu Hemşirelik ve Sağlık Bilimleri Dergisi, 22(4), 306-312. https://doi.org/10.17049/ataunihem.456565
World Union of Wound Healing Societies (WUWHS) Consensus Document. Wound exudate: Effective assessment and management Wounds International, 2019. Erişim: https://woundsinternational.com/
Doğu, Ö., & Önen, S. (2020). Basınç ülseri takip ve tedavisinde kullanılan ölçekler. Yoğun Bakım Hemşireliği Dergisi, 24(3), 199-208.
Iizaka S, Sanada H, Nakagami G et al (2011) Quantitative estimation of exudate volume for full-thickness pressure ulcers: the ESTimation method. J Wound Care 20(10): 453–63
Falanga V (2000) Classifications for wound bed preparation and stimulation of chronic wounds. Wound Rep Reg 8(5): 347–52
Bates-Jensen BM (2001) Bates-Jensen wound assessment tool. Instructions for use. Available at: www.southwesthealthline.ca/healthlibrary_docs/B.6.1b.Bates- JensenTool.pdf
World Union of Wound Healing Societies (WUWHS) (2007) Principles of best practice: Wound exudate and the role of dressings. A consensus document. London: MEP Ltd. Available at: www.woundsinternational.com
Gethin G, Grocott P, Probst S, Clarke E (2014) Current practice in the management of wound odour: an international survey. Int J Nurs Studies 51: 865–74. https://doi.org/10.1016/j.ijnurstu.2013.10.013
Nix D (2016) Skin and wound inspection and assessment. In: Acute and Chronic Wounds: Current Management Concepts, 5th edition. Missouri: Elsevier: 109–23
Grocott P (2001) Developing a tool for researching fungating wounds. World Wide Wounds. Available at: www.worldwidewounds.com/2001/july/Grocott/Fungating- Wounds.html
Foltynski, P., Ciechanowska, A., & Ladyzynski, P. (2021). Wound surface area measurement methods. Biocybernetics and Biomedical Engineering, 41(4), 1454-1465.
Özer E. Diyabetik ayak. Kalp Damar Cerrahisinde Yara Bakım Ortak Görüş, Editör: Doç. Dr. Cenk Eray Yıldız, Öğr. Gör. Dr. Eren Karpuzoğlu, Doç.Dr. Murat Uğur, Editör, Bayçınar Tıbbi Yayıncılık ve Reklam Hiz. Tic. Ltd. Şti., İstanbul, ss.3-16, 2021
Li, S., Renick, P., Senkowsky, J., Nair, A., & Tang, L. (2021). Diagnostics for wound infections. Advances in wound care, 10(6), 317-327.
Kadanalı, A., SALTOĞLU, N., Ak, Ö., Aktaş, Ş., ALTAY, F., Bayraktaroğlu, T., ... & Yontar, N. (2024). Diagnosis, Treatment, Prevention, and Rehabilitation of Diabetic Foot Ulcers and Infections: Turkish Consensus Report, 2024 Diyabetik Ayak Yarası ve İnfeksiyonunun Tanısı, Tedavisi, Önlenmesi ve Rehabilitasyonu: Ulusal Uzlaşı Raporu, 2024. Klimik Dergisi, 37(1).
Woo KY, Sibbald RG. A cross-sectional validation study of using NERDS and STONEES to assess bacterial burden. Ostomy Wound Manage. 2009; 55(8): 40-48.
Eyi, S. (2023). Nurses' Knowledge and Attitudes in Relation to Wound Infection and Wound Culture: A Quasi-Experimental Study. Turkiye Klinikleri Journal of Nursing Sciences, 15(4).
Rahimi, R., Ochoa, M., Parupudi, T., Zhao, X., Yazdi, I. K., Dokmeci, M. R., ... & Ziaie, B. (2016). A low-cost flexible pH sensor array for wound assessment. Sensors and Actuators B: Chemical, 229, 609-617.
Bairagi, A., Frear, C., Sweeting, C., Kimble, R., & Griffin, B. (2022). A pilot study comparing two burn wound stereophotogrammetry systems in a paediatric population. Burns, 48(1), 85-90.
Houghton, P. (2018). Research 101: wound Assessment tools. Wound Care Canada, 16(1), 58-64.
Smet, S., Probst, S., Holloway, S., Fourie, A., Beele, H., & Beeckman, D. (2021). The measurement properties of assessment tools for chronic wounds: a systematic review. International journal of nursing studies, 121, 103998.
Köze, B. Ş., & Özbayır, T. Toronto Yara Semptom Değerlendirme Sistemi ile Yara Bakımının İzlenmesi. Yoğun Bakım Hemşireliği Dergisi, 27(3), 156-163.
Schulz, V., Kozell, K., Biondo, P. D., Stiles, C., Tonkin, K., & Hagen, N. A. (2009). The malignant wound assessment tool: a validation study using a Delphi approach. Palliative Medicine, 23(3), 266-273.
Do, H. T. T., Edwards, H., & Finlayson, K. (2022). Development of a surgical wound assessment tool to measure healing and risk factors for delayed wound healing in Vietnam: a Delphi process. Journal of wound care, 31(5), 446-458.
Uğur E., Uslu Y. Basınç Yaralanması. Kalp Damar Cerrahisinde Yara Bakım Ortak Görüş, Editör: Doç. Dr. Cenk Eray Yıldız, Öğr. Gör. Dr. Eren Karpuzoğlu, Doç.Dr. Murat Uğur, Editör, Bayçınar Tıbbi Yayıncılık ve Reklam Hiz. Tic. Ltd. Şti., İstanbul, ss.145-160, 2021
Fletcher, J. (2007). Wound assessment and the TIME framework. British journal of nursing, 16(8), 462-466.
Obilor, H. N., Omolara, A. B., & Omolara, A. O. (2021). A survey of nurses' wound assessment knowledge, attitude and competence in Nigeria. Wound Practice & Research: Journal of the Australian Wound Management Association, 29(3), 140-147.
Sürme, Y., Kartın, P. T., & Çürük, G. N. (2018). Knowledge and practices of nurses regarding wound healing. Journal of PeriAnesthesia Nursing, 33(4), 471-478.
Oseni OM, Adejumo PO. Nurses’ reported practice and knowledge of wound assessment, assessment tools and documentation in a selected hospital in Lagos, Nigeria. Afr J Med Med Sci 2014;43(2):149–57.
Referanslar
Grey, J. E., Enoch, S., & Harding, K. G. (2006). Wound assessment. BMJ, 332(7536), 285–288. doi:10.1136/bmj.332.7536.285
Greatrex-White S, Moxey H.Wound assessment tools and nurses’ needs: an evaluation study. Int Wound J 2015; 12:293–301. doi: 10.1111/iwj.12100
Benbow, M. (2016). Best practice in wound assessment. Nursing standard, 30(27).
Nichols, E. L. I. Z. A. B. E. T. H. (2016). Wound assessment part 2: exudate. Wound Essentials, 11(1), 36-41.
Öngel, K., Mergen, H. (2008). New wound dressing products under the light of literature. Turkish Journal of Surgery, 24(2):104-108.
Nagle, S. M., Stevens, K. A., & Wilbraham, S. C. (2018). Wound assessment.
Moura, M., Dowsett, C., Bain, K., & Bain, M. (2020). Advancing practice in holistic wound management: a consensus-based call to action. Wounds International, 11(4), 70-75.
Tan, P., Lim, J., & Moiemen, N. (2021). Imaging techniques used for wound healing assessment: A systematic review part 1 chronic wounds. European Burn Journal, 2(4), 194-214.
Nichols, E. (2015). Wound assessment part 1: How to measure a wound. Wound Essentials, 10(2), 51-5.
Savcı, A. Yara Değerlendirme ve TIME Yaklaşımı. Erişim: https://hmyo.ankara.edu.tr/wp-content/uploads/sites/438/2019/03/Yara-Tan%C4%B1lama-ve-T%C4%B0ME-yakla%C5%9F%C4%B1m%C4%B1.pdf
Toklu, A. S. Kronik Yarada Ölçme ve Değerlendirme. Ed: Topalan M, Aktaş Ş. Güncel Yönleriyle Kronik Yara. Aygül Ofset Matbaacılık San. Tic. Ltd. Şti.1. Baskı, Şubat, Ankara. 2010: 27-31.
Bowers, S., & Franco, E. (2020). Chronic wounds: evaluation and management. American family physician, 101(3), 159-166.
Asgarpour, H. Venöz Ayak Ülser Tedavisinde Güncel Yaklaşımlar. Süleyman Demirel Üniversitesi Sağlık Bilimleri Dergisi, 10(3), 333-339. https://doi.org/10.22312/sdusbed.560995
Öztaş, P. (2021). Yara iyileşmesi, bakımı ve tedavisi. Ankara Eğitim ve Araştırma Hastanesi Tıp Dergisi, 54(2), 341-351.
Eraydın, Ş., & Avşar, G. (2019). Diyabetik Ayak Ülserinde Fiziksel Muayene ve Hemşirelik Bakimi. Anadolu Hemşirelik ve Sağlık Bilimleri Dergisi, 22(4), 306-312. https://doi.org/10.17049/ataunihem.456565
World Union of Wound Healing Societies (WUWHS) Consensus Document. Wound exudate: Effective assessment and management Wounds International, 2019. Erişim: https://woundsinternational.com/
Doğu, Ö., & Önen, S. (2020). Basınç ülseri takip ve tedavisinde kullanılan ölçekler. Yoğun Bakım Hemşireliği Dergisi, 24(3), 199-208.
Iizaka S, Sanada H, Nakagami G et al (2011) Quantitative estimation of exudate volume for full-thickness pressure ulcers: the ESTimation method. J Wound Care 20(10): 453–63
Falanga V (2000) Classifications for wound bed preparation and stimulation of chronic wounds. Wound Rep Reg 8(5): 347–52
Bates-Jensen BM (2001) Bates-Jensen wound assessment tool. Instructions for use. Available at: www.southwesthealthline.ca/healthlibrary_docs/B.6.1b.Bates- JensenTool.pdf
World Union of Wound Healing Societies (WUWHS) (2007) Principles of best practice: Wound exudate and the role of dressings. A consensus document. London: MEP Ltd. Available at: www.woundsinternational.com
Gethin G, Grocott P, Probst S, Clarke E (2014) Current practice in the management of wound odour: an international survey. Int J Nurs Studies 51: 865–74. https://doi.org/10.1016/j.ijnurstu.2013.10.013
Nix D (2016) Skin and wound inspection and assessment. In: Acute and Chronic Wounds: Current Management Concepts, 5th edition. Missouri: Elsevier: 109–23
Grocott P (2001) Developing a tool for researching fungating wounds. World Wide Wounds. Available at: www.worldwidewounds.com/2001/july/Grocott/Fungating- Wounds.html
Foltynski, P., Ciechanowska, A., & Ladyzynski, P. (2021). Wound surface area measurement methods. Biocybernetics and Biomedical Engineering, 41(4), 1454-1465.
Özer E. Diyabetik ayak. Kalp Damar Cerrahisinde Yara Bakım Ortak Görüş, Editör: Doç. Dr. Cenk Eray Yıldız, Öğr. Gör. Dr. Eren Karpuzoğlu, Doç.Dr. Murat Uğur, Editör, Bayçınar Tıbbi Yayıncılık ve Reklam Hiz. Tic. Ltd. Şti., İstanbul, ss.3-16, 2021
Li, S., Renick, P., Senkowsky, J., Nair, A., & Tang, L. (2021). Diagnostics for wound infections. Advances in wound care, 10(6), 317-327.
Kadanalı, A., SALTOĞLU, N., Ak, Ö., Aktaş, Ş., ALTAY, F., Bayraktaroğlu, T., ... & Yontar, N. (2024). Diagnosis, Treatment, Prevention, and Rehabilitation of Diabetic Foot Ulcers and Infections: Turkish Consensus Report, 2024 Diyabetik Ayak Yarası ve İnfeksiyonunun Tanısı, Tedavisi, Önlenmesi ve Rehabilitasyonu: Ulusal Uzlaşı Raporu, 2024. Klimik Dergisi, 37(1).
Woo KY, Sibbald RG. A cross-sectional validation study of using NERDS and STONEES to assess bacterial burden. Ostomy Wound Manage. 2009; 55(8): 40-48.
Eyi, S. (2023). Nurses' Knowledge and Attitudes in Relation to Wound Infection and Wound Culture: A Quasi-Experimental Study. Turkiye Klinikleri Journal of Nursing Sciences, 15(4).
Rahimi, R., Ochoa, M., Parupudi, T., Zhao, X., Yazdi, I. K., Dokmeci, M. R., ... & Ziaie, B. (2016). A low-cost flexible pH sensor array for wound assessment. Sensors and Actuators B: Chemical, 229, 609-617.
Bairagi, A., Frear, C., Sweeting, C., Kimble, R., & Griffin, B. (2022). A pilot study comparing two burn wound stereophotogrammetry systems in a paediatric population. Burns, 48(1), 85-90.
Houghton, P. (2018). Research 101: wound Assessment tools. Wound Care Canada, 16(1), 58-64.
Smet, S., Probst, S., Holloway, S., Fourie, A., Beele, H., & Beeckman, D. (2021). The measurement properties of assessment tools for chronic wounds: a systematic review. International journal of nursing studies, 121, 103998.
Köze, B. Ş., & Özbayır, T. Toronto Yara Semptom Değerlendirme Sistemi ile Yara Bakımının İzlenmesi. Yoğun Bakım Hemşireliği Dergisi, 27(3), 156-163.
Schulz, V., Kozell, K., Biondo, P. D., Stiles, C., Tonkin, K., & Hagen, N. A. (2009). The malignant wound assessment tool: a validation study using a Delphi approach. Palliative Medicine, 23(3), 266-273.
Do, H. T. T., Edwards, H., & Finlayson, K. (2022). Development of a surgical wound assessment tool to measure healing and risk factors for delayed wound healing in Vietnam: a Delphi process. Journal of wound care, 31(5), 446-458.
Uğur E., Uslu Y. Basınç Yaralanması. Kalp Damar Cerrahisinde Yara Bakım Ortak Görüş, Editör: Doç. Dr. Cenk Eray Yıldız, Öğr. Gör. Dr. Eren Karpuzoğlu, Doç.Dr. Murat Uğur, Editör, Bayçınar Tıbbi Yayıncılık ve Reklam Hiz. Tic. Ltd. Şti., İstanbul, ss.145-160, 2021
Fletcher, J. (2007). Wound assessment and the TIME framework. British journal of nursing, 16(8), 462-466.
Obilor, H. N., Omolara, A. B., & Omolara, A. O. (2021). A survey of nurses' wound assessment knowledge, attitude and competence in Nigeria. Wound Practice & Research: Journal of the Australian Wound Management Association, 29(3), 140-147.
Sürme, Y., Kartın, P. T., & Çürük, G. N. (2018). Knowledge and practices of nurses regarding wound healing. Journal of PeriAnesthesia Nursing, 33(4), 471-478.
Oseni OM, Adejumo PO. Nurses’ reported practice and knowledge of wound assessment, assessment tools and documentation in a selected hospital in Lagos, Nigeria. Afr J Med Med Sci 2014;43(2):149–57.
