Functional capacity and quality of life of patients with chronic wounds

Universidade Estadual do Piauí – Centro de Ciências da Saúde – Departamento de Enfermagem – Teresina/PI – Brazil. Corresponding author: Aline Costa de Oliveira | Universidade Estadual do Piauí – Centro de Ciências da Saúde – Departamento de Enfermagem | Rua Olavo Bilac, 2335 – Centro (Sul) | ZIP Code: 64001-280 – Teresina/PI – Brazil | E-mail: alinecosta.1@hotmail.com Received: June 06 2018 | Accepted: Sept. 11 2018 ABSTRACT Objective: To evaluate functional capacity and quality of life (QoL) of patients with chronic wounds. Methods: A cross-sectional analytical study composed of 74 patients with chronic wounds accompanied at a reference center for the treatment of complex wounds in Teresina, state of Piaui. Data were collected using the Katz index and the Cardiff Wound Impact Schedule. Results: Among the domains, the “well-being” had a lower mean score and the degree of dependence obtained a signifi cant association with the well-being and “social life” domains. The bathing, dressing, personal hygiene and locomotion activities showed an association between the domains of QoL. Conclusion: The degree of independence in performing the basic activities of daily living, especially bathing, dressing and personal hygiene, presented higher scores between domains, indicating a better QoL. It is expected that the implantation of measures that help to preserve the functional capacity will improve the patients’ QoL.


INTRODUCTION
Chronic wounds refer to skin injurys with delayed healing, comprising a period of more than 6 weeks and presenting a high rate of recurrences.These wounds are characterized by a delay in the physiological repair that leads to a pathological inflammatory state and causes physical, psychosocial and economic changes in people affected by them 1,2 .
Wounds chronification has become a concern both for health professionals and health systems because it is associated with continuous, expensive and prolonged treatments, with inevitable consequences in the different dimensions of the patient's/family life and, consequently, in their quality of life (QoL) and functional capacity 3 .
Chronic wounds can cause pain, edema and impair mobility, factors that negatively affect patients' functional capacity, since its lead problems related to social interaction, loss of self-esteem, poor self-care, and, consequently, compromise QoL 4 .
The QoL includes "the individual's perception of their position in life, in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns" 5 .The evaluation of QoL is considered a measure of health outcome, since it attends to the assumption of individualizing attention and considering the subjectivity of the person attented 6 , making clear the necessity to realize studies that cover this subject and the therapeutic alternatives existing nowadays 7 .
According to the international classification of commitment, disabilities and disadvantages of World Health Organization (WHO), functional capacity is considered the absence of difficulties in performing daily activities 8 .Functional capacity is fundamental for the maintenance of the well-being and the autonomy of the people and the presence of the wounds can develop or influence a situation of dependence, negatively affecting
the physical, social and psychological dimensions directly related to the QoL.Thus, the functional capacity assessment allows to investigate the independence to perform the basic activities and becomes relevant in determining the health conditions of people and in the development of interventions to improve their lives 9 .
It should be emphasized that there are still few studies that approach QoL and functional capacity in people with chronic wounds, however, understanding the conditions lived by this population is fundamental to health professionals, since the process of slow wound repair causes loss of selfesteem and disabilities condition 4 .us, the necessity for professional support is emphasized, mainly in changes of conduct based on the real needs of patients, prioritizing the reduction of complications, besides helping in the processes of acceptance and adaptation.erefore, the objective of this study was to evaluate the functional capacity and QoL of patients with chronic wounds.

METHODS
A descriptive, cross-sectional, analytical study with a quantitative approach developed at a reference center for treatment of complex wounds in Teresina, state of Piaui, Brazil, from February to May 2017.e population was consisted of patients attented at the outpatient clinic complex wounds for evaluation and treatment of the injury during the period of data collection, totaling 74 patients.As inclusion criteria, it were considered people aged 18 years or older and with a injury duration of more than 6 weeks, and the exclusion criteria were focused on people with cognitive impairment to complete the questionnaires and on the elderly who did not reach the minimum score in mental assessment.e data collection was guided by a form adapted for sociodemographic characterization (gender, age, origin, marital status, income and schooling) and clinical (risk factors, etiology, anatomical location, time of existence, tissue type, quantity and appearance of the exudate, initial and nal extension, coverages and products used and frequency between exchanges) 10 and by the Mental Assessment Questionnaire 11 applied to people aged 60 years and over, being selected those who obtained at least seven hits.Also, the Cardi Wound Impact Schedule (CWIS) questionnaire was used to measure QoL 12 and the Katz 13 index for functional capacity assessment.The CWIS consists of a speci c and self-validated tool, validated in the Brazilian version 14 , with good internal consistency (Cronbach α = 0.920) and composed of 47 items distributed in the domains "well-being" (seven items), "physical symptoms and daily life" (24 items), "social life" (14 items) and self-assessment of QoL 2 .e items are classi ed as Likert-type scale and transformed into scores ranging from 0 to 100, where the higher the score, will be better the QV 12 .e Katz index is commonly used to measure the degree of independence and functional capacity in the performance of six functions of daily life, such as: feeding, continence, transference (locomotion), go to the toilet, dressing and bathing 13,15 .

RESULTS
Of the 74 participants, 39 (52.7%) were men, 31 (41.9%) in the 41-59 age group and 32 retirees (43.2%).As to mobility, 35 (47.3%) wandered without assistance.There were predominant wounds of vasculogenic origin in 26 (35.1%) people and traumatic in 22 (29.7%).About QoL, Table 1 presents the scores of the CWIS questionnaire.The domain with the lowest mean score was well-being, presenting a mean of 33.2 ± 17.2, while the physical symptoms domains and daily life and social life had a mean score of 66.9 ± 17.5 and 65.6 ± 19.7, respectively.
Oliveira AC, Alvarenga AS, Freitas FS, Rocha DM, Bezerra SMG, Nogueira LT Regarding functional capacity, it was verified that 66 (89.2%) patients performed their basic activities of daily living.As for the association between degree of dependence and QoL, the well-being and social life domains were significant and independent people differed statistically from dependents in the social life domain (Table 2).
The evaluation of the activities of bathing, dressing, personal hygiene, locomotion, continence and feeding showed a higher frequency of independent patients in all activities (Table 3).
In relation to the basic activities of daily living and QoL, bath presented a significant association with all well-being domains (p = 0.006), physical symptoms and daily life (p = 0.007) and social life (p = 0.009).Capacidade funcional e qualidade de vida de pacientes com feridas crônicas Dressing was associated with well-being domains (p = 0.018), physical symptoms and daily life (p = 0.025) and social life (p = 0.030).Personal hygiene was positively associated with the social life domain (p = 0.015) and locomotion was significant when associated with physical symptoms and daily life domains (p = 0.034) and social life (p = 0.024).

DISCUSSION
The characterization of the sociodemographic variables identified that the majority of the patients were men and located in the age group between 41-59 years, generating direct repercussions in the health services and in the home environment, since the chronicity of the wounds promotes the increase of costs and leads to the distancing of work activities or early retirement 5 , which is the predominant occupational situation in the study participants.
About 47.3% of the studied population wandered without assistance and had wounds of vasculogenic origin.These injuries are usually accompanied by intense pain, exudate, and odor, with slow healing that, together with psychosocial factors and care dependence, affects functional capacity and affects QoL 16,17 .
The well-being domain presented lower mean QoL score, while the physical symptoms domains and daily life and social life had similar and higher average scores.These results are consistent with other studies that also used the CWIS questionnaire to assess the QoL of people with wounds 18,19 .
Well-being is related to anxiety levels, involving emotional perception that is related to the existence of positive emotions and absence of negative emotions, involving factors such as life satisfaction, confrontation skills, optimism and perspective for the future 19,20 .Patients with ulcers often experience negative emotions such as shame, embarrassment, depression, concern that the condition worse, apathy and mental problems, coexisting with a strong feeling of loneliness 6 .
Other studies also revealed a negative impact of skin injuries on QoL related to the emotional sphere, especially in patients with chronic ulcers 6,21 .The progressive and chronic character of wounds affects the most important spheres of human life, and it is important to have comprehensive care covering all aspects of impaired functioning in the physical, psychosocial and emotional spheres 22 .
In the present study, the functional capacity was also evaluated, identifying a low impact in relation to the degree of dependence, since 89.2% of the people presented themselves independently for all activities 23 .
However, when associated with QoL, the well-being and social life domains were significant.
Previous studies have shown that long-term disabilities, particularly those that affect routine daily activities, have an indirect correlation with mental health and Qol 24,25 .Relying on other people for the performance of daily topics is a predictable outcome in the face of compromised QoL.Thus, providing adequate services to these people can reduce their dependence and have a positive impact on their QoL increase 25 .
The results show that most of the participants did not present difficulties in the bath, to dress themselves, to perform their personal hygiene, in locomotion, continence and feeding.These daily activities do not directly interfere with the life of patients with chronic wounds, since to perform these activities, the upper limbs are also used, the region of the body less affected by wounds 26 .
In The presence of self-care impairments was evidenced by difficulties in wandering, dressing and bathroom use, also verified in other studies that evaluated the impact of the injury on patients' functional capacity 28 .Thus, it is considered that this problem may directly reflect on care for their own wound, presuming the dependence on care and the continued need for support from family members and health professionals.
Oliveira AC, Alvarenga AS, Freitas FS, Rocha DM, Bezerra SMG, Nogueira LT According to the literature, the reason for the limitations of daily activities in patients with wounds is also in uencing dressings, recurrences and a high time of treatment that can cause di culties in moving or the necessity to prevent complications 29 .In addition, these limitations may be associated with the presence of severe pain and exudation and unpleasant wound smell 6 , thus in uencing lower levels of QoL and impairment of functional capacity.

CONCLUSION
This study demonstrated that the presence of chronic wounds negatively a ects the QoL of the patients and that the well-being domain interfered directly for worse QoL, generating physical, social and emotional impacts.In addition, it was observed a signi cant degree of independence in performing the basic activities of daily living, with emphasis on bathing, dressing, personal hygiene and higher scores between domains, which led to an improvement in QoL.
Thus, the implantation of measures that help to preserve the functional capacity and that provide the accomplishment of the daily activities and of the selfcare implies in the possibility of an autonomous and socially active life.In this way, future research focusing on comprehensive interventions that promote the rehabilitation of wounded people in the execution of their activities and the improvement of QoL is necessary.
e data was entered into double-entry worksheets in Microsoft O ce Excel and later exported to the Statistic Package for Social Sciences (SPSS) version 22 aiming the descriptive and inferential analysis.Measurements of central (mean and median), dispersion (standard deviation) and minimum and maximum values for the quantitative variables and proportions for the categorical were calculated.In the inferential analysis, the Kolmogorov-Smirnov test was performed to verify data normality, Kruskal Wallis and Mann-Whitney U tests (nonparametric comparative tests), Student's t-test and analysis of variance (ANOVA) (comparative parametric tests).e signi cance criterion adopted in the study was the level of 5% (p <0.05).Participants who accepted to be part of the study signed the Informed Consent Term (TCLE). is research followed the ethical and legal precepts contained in Resolution 466/2012 of the National Health Council and was approved by the Research Ethics Committee of the Federal University of Piauí under opinion 1.837.210.
the case of daily activities, the bath presented association in all areas of well-being, physical symptoms and daily life and social life.The act of dressing presented association with the domains well-being, physical symptoms and daily life and social life.Personal hygiene was positively associated with social life domain and locomotion was significant when associated with domains physical symptoms and daily life and social life.It is worth highlighting that in the literature the relationship between the presence of wounds and the compromise of well-being is evident, since physical limitations and difficulties in the development of daily, social and work activities are common, as well as dependence on care 27 .

Table 2 .
Association between degree of dependence and quality of life of patients with chronic wounds, Teresina, state of Piaui, *Median (minimum-maximum); † p-value of Kruskal Wallis; ‡ Mean ± standard deviation; § Analysis of variance (ANOVA).

Table 3 .
Association between basic activities of daily living and domains of quality of life, Teresina, state of Piaui, Brazil, 2018 (n = 74).