Wound Care Basics: Subjective Assessment

Original Editor - Stacy Schiurring based on the course by Dana Palmer
Top Contributors - Stacy Schiurring and Jess Bell

Introduction

"A common mantra in wound care is to consider the WHOLE patient, not just the HOLE in the patient." -Dana Palmer PT

It is essential to remember that wounds are often caused by one or more underlying conditions. These conditions will affect the established goals, treatment plan, prognosis, and patient education. The wound clinician must consider the patient's anatomical makeup, physiological functioning, and their environment while performing the wound assessment.

When to Refer to a Higher Level of Care

It is important to always assess a patient as a whole person and note any systemic symptoms beyond the boundaries of the wound itself. The following is a list of potential findings which would trigger a referral back to the primary care physician or to an urgent or emergency care facility.

For more information on clinical red flags, please review this page. Please also review the flag system to learn about other clinical flags to keep a look out for during patient interviews.

Subjective complaints / signs or symptoms	Potential risk
New onset or worsening of fever and malaise, especially if combined with increased pain, erythema, oedema, or odour	Systemic infection or sepsis
Erythema more than two centimetres beyond the wound border in a neuropathic ulcer Patients with diabetes often don't present with the typical signs of wound infection. In these cases, you may also see copious serous drainage from the wound.	Local wound infection
Being able to probe to bone or visible bone in a wound, especially if combined with fever, oedema, erythema and odour, or other signs of an infection	Osteomyelitis
Erythema, oedema, deep pain, and skin that is hot to the touch, especially if spreading quickly Fever may also be seen in these cases, but not always	Deep vein thrombosis (DVT), infection, cellulitis, or necrotising fasciitis
Chest pain	angina or an acute myocardial infarction (MI)
Shortness of breath with bilateral lower extremity oedema	Congestive heart failure or renal failure
Rash, itching, oedema, and shortness of breath	Drug allergy or drug-induced hypersensitivity syndrome
Blisters and pain along a dermatome	Acute onset of herpes zoster (shingles)
A dark mole with asymmetry, uneven borders, changing colour, more than one centimetre in diameter, and evolving, especially if that mole is bleeding or scabbing	Melanoma
Lower extremity pain that increases with activity or awakens a patient at night along with extremities that are cool to the touch and absent or weak pulses	Moderate to severe peripheral arterial disease
Syncope and dizziness	Hypotension, hypoglycaemia
Decreased mental status	Hyperglycaemia, cerebrovascular event (such as a transient ischemic attack or a cerebrovascular accident)
Bleeding in the wound that is not controlled by pressure	Arterial leak, a high international normalised ratio (INR), or a low platelet count
Sudden new onset of bruising in a distal extremity	Acute peripheral arterial occlusion
Erythema, warm skin, and pain with weight bearing in a patient with diabetes	Acute Charcot foot

Special Topic: Hypoglycemia versus Hyperglycemia

Hyperglycaemia (high blood sugar) can occur in persons with type 1 diabetes and type 2 diabetes and people who are pregnant in the form of gestational diabetes. It can also be an issue for people who do not have diabetes, but have recently had a stroke, myocardial infarction, or have a severe infection.

Symptoms of hyperglycaemia in people with diabetes tend to develop slowly over a few days or weeks. In some cases, there may be no symptoms until the blood sugar level is very high.

Symptoms of hyperglycaemia include:

• increased thirst and dry mouth
• frequent urination
• tiredness
• blurred vision
• unintentional weight loss
• recurrent infections, such as thrush, bladder infections and skin infections

The following symptoms could be a sign of diabetic ketoacidosis and warrant emergency services when combined with measured high blood sugar:

• extreme thirst
• fast, deep breathing
• dry skin and mouth
• flushed face
• fruity-smelling breath
• headache
• muscle stiffness or aches
• being very tired
• nausea and vomiting
• stomach pain
• difficulty staying awake

Hypoglycaemia (low blood sugar) is most commonly associated with diabetes but can occur in persons without diabetes due to severe malnutrition, binge drinking or medical conditions such as Addison's disease.

Early warning signs:

• feeling hungry
• trembling or shakiness
• sweating

Signs in more severe cases include:

• confusion
• difficulty concentrating
• loss of consciousness

If a patient is experiencing low blood sugar, first check their blood glucose levels. According to the Center for Disease Control and Prevention (CDC), if the patient's blood glucose measures between 55-69 mg/dL, follow the 15-15 rule: give them 15 grams of carbs and recheck their blood glucose after 15 minutes. Repeat if they are still below their target range. If their blood glucose level is below 55 mg/dL, it is considered severely low and should be treated with injectable glucagon. If this is not available or you are not trained to give this injection, call for emergency help immediately. Emergency services should also be alerted after injectable glucagon is given for full patient assessment.

Please view the following short video to learn how to recognise the signs and symptoms of a CVA (stroke).

Patient Interview

This is a time to gather information from the patient, as well as build rapport and trust before starting the hands-on wound assessment. While this is essential for any patient-clinician relationship, it can be even more important when dealing with wounds and feelings of fear, shame and uncertainty. The subjective history will also give insight if any potential referrals to other members of the medical team are required, such as for dietetics, diabetes management, smoking cessation, or drug/alcohol counselling.

Below are a list of sample questions specific to a wound care subjective interview. For a more complete list of subjective questions, please see the additional resources section at the bottom of the page.

Subjective History and Timeline of the Wound

• How long has this wound been present? This speaks to chronicity and also the healing potential.
• How did the wound start? Was it sudden or was it gradual?
• Have they had similar wounds before?
• What treatments have been used and what was the outcome?
• History of infection or delayed healing?
• Has a wound culture been taken?
• Have imaging studies such as X-rays or magnetic resonance imaging (MRI) been performed?
• What about any other labs such as complete blood count (CBC)?

Past Medical History

• What medical diagnoses are present?
  • Many health conditions will affect wound healing, make special note of the following: (1) diabetes, (2) congestive heart failure, (3) hypertension, (4) peripheral vascular disease.
• What medications is the patient currently taking? The following will delay wound healing: (1) steroids, (2) non-steroidal anti-inflammatory drugs (NSAIDs), (3) immunosuppressive medications, and (4) chemotherapy medications.
• Does the patient take medications as prescribed?
• Basic nutrition, water intake, any supplements they may be taking
• Smoking history
• Use of alcohol or illegal drugs

Pain

• Does the patient experience any pain?
• Is the pain at the wound site or is it in other areas?
• Is there any paraesthesia or anaesthesia?
• Are symptoms relieved or worsened by elevation, rest, or activity?
• What increases and decreases pain or other symptoms?

Please view the following short video to learn how to recognise the signs of a DVT and see an example in a real patient.

Occupation and Social History

• How the patient spends their day with respect to limb position, weight bearing, activity, and pressure at work and home
• Average amount of sleep and if the wound has affected their sleep
• Exercise routine and leisure activities, and if the wound has changed their ability to participate in these activities

Patient's Input

• What are the patient's primary concerns at this time?
• What are their top goals?
• What does the patient see as their biggest limitation to healing?
• How committed is the patient to making lifestyle changes?

Resources

Optional Recommended Reading:

• Oedema Management

Clinical Resources:

• Sample Questions of Subjective Wound History
• Pain Visual Analogue Scale
• Readiness for Change Questionaire