Lázaro-Martínez José Luis, Conde-Montero Elena, Alvarez-Vazquez Juan Carlos, Berenguer-Rodríguez Juan José, Carlo Amparo Galindo, Blasco-Gil Silvia, Blasco-García Carmen, Martínez-Cuervo Fernando
Diabetic Foot Unit. Universidad Complutense de Madrid. Madrid, Spain.
Dermatology Department. Hospital Infanta Leonor. Madrid. Spain.
J Wound Care. 2018 Nov 2;27(11):790-796. doi: 10.12968/jowc.2018.27.11.790.
Wound assessment is an essential part of wound management and has traditionally focused on the wound bed. The Triangle of Wound Assessment (Triangle) is a new assessment tool that includes a holistic evaluation of the patient with a wound. The aim of this pilot study was to describe the use of the Triangle in our clinical practice in Spain.
Prospective, consecutive patients, male and female, over 18 years old, with wounds of any aetiology and duration, who attended the centres involved in the study, were recruited between May and June 2017. The TWA was used during the first presentation, to assess the wound bed, edge and periwound skin. The study's expert panel met to discuss the results collected by the assessment, as well as the advantages and disadvantages of the system.
We recruited 90 patients. Non-viable tissue (necrotic/sloughy) was recorded in 57.8% of the patients, elevated exudate (medium/high) in 52.2%. Approximately 25% of the patients had signs or symptoms of local infection. Maceration was the most prevalent issue recorded on the wound edge and periwound skin assessment, affecting 31.1% and 30.0% of the patients, respectively. The presence of hyperkeratosis was high for the study population as the main aeitologies of the wounds identified here were DFU.
The implementation of Triangle Wound Assessment could help in the holistic approach to patient care by focusing on more than local wound care, identifying barriers to achieving wound healing and evaluating wound response and patient compliance.
伤口评估是伤口管理的重要组成部分，传统上主要关注伤口床。伤口评估三角法（三角法）是一种新的评估工具，它对有伤口的患者进行全面评估。这项初步研究的目的是描述三角法在西班牙我们临床实践中的应用情况。
2017年5月至6月期间，招募了年龄在18岁以上、患有任何病因和病程的伤口的前瞻性连续患者，包括男性和女性，他们前往参与研究的中心就诊。在首次就诊时使用伤口评估三角法，以评估伤口床、边缘和伤口周围皮肤。研究的专家小组开会讨论评估收集到的结果以及该系统的优缺点。
我们招募了90名患者纳入研究。57.8%的患者记录有失活组织（坏死/腐肉样），52.2%的患者有渗出物增多（中度/高度）。约25%的患者有局部感染的体征或症状。浸渍是伤口边缘和伤口周围皮肤评估中记录到的最普遍问题，分别影响31.1%和30.0%的患者。由于此处确定的伤口主要病因是糖尿病足溃疡，研究人群中角化过度的发生率较高。
实施伤口评估三角法有助于采用整体方法进行患者护理，不仅关注局部伤口护理，还能识别伤口愈合的障碍，评估伤口反应和患者依从性。
