Wound Care Basics: Subjective Assessment

Original Editor - Stacy Schiurring based on the course by [ https://members.physio-pedia.com/instructor/dana-palmer//instructor/dana-palmer/ 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

In this course, we are going to go over basic wound assessment, including subjective history, objective evaluation, basic wound classification, and identifying cases that require referral or further medical intervention.

It is essential to remember that the wound you are assessing is most often caused by one or more underlying conditions. These conditions will affect your goals, treatment plan, prognosis, and patient education. The wound clinician must consider the patient's anatomical makeup, physiological functioning, and their environment. The scope of your wound assessment will vary based on where you are practising and how much autonomy that you have. In some situations, a patient may come to you for treatment only with specific orders. In these cases, you should still complete a wound assessment. In other situations, a patient may come to you with an order for a full evaluation. These assessments are in some ways more critical because you may be the first healthcare provider that has thoroughly looked at the wound.

When assessing a wound, you want to have these questions in the back of your mind. What type of wound is this? What stage of healing is this wound in? What is the first thing I want to do to progress healing? And how can I best accomplish this in a way that utilises the tools that I have available, aligns with the patient's goals, and does not damage healthy tissue? Considering these things will help to guide your 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, so 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.	DVT (deep vein thrombosis), infection, cellulitis, or necrotising fasciitis
Chest pain	angina or an acute MI (myocardial infarction).
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 or 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
decreased mental status	cerebrovascular event such as a TIA (transient ischaemic attack) or a CVA (cerebrovascular accident).
Bleeding in the wound that is not controlled by pressure	arterial leak, a high INR (international normalised ratio), 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 be an issue for people not diagnosed with diabetes but who have recently had a stroke, myocardial infarction, or have a severe infection.

Subjective History

This is not only when you can gain the most relevant information about your patient's condition, but also an opportunity to build rapport and trust, right? This is essential for any patient-clinician relationship. But it can be even more important when dealing with wounds where there may be a lot of fear, misinformation, shame and uncertainty involved.

Some of these patients have had wounds for a long time. Here are some of the key things you want to consider in your subjective history.

1. So starting with the wound history itself. So 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? This will give you information about skin integrity and also some clues about lifestyle factors to avoid or alter when you are treatment planning. You want to know if the wound started with scratching or itching, because if it was itchy, that can indicate that the skin may need moisturisation. The patient may need strategies to reduce scratching. There may also be underlying vascular pathology that needs to be addressed that's causing that persistent itching. If the wound started with a blister, friction, or pressure from shoes, that will tell you that footwear type and size needs to be considered, and that once the wound has healed, the patient may need custom footwear to reduce that pressure.
2. Okay, next. What medical diagnoses are present? So many health conditions will affect wound healing. Does the patient have diabetes? If so, they have an increased risk of infection and decreased ability to rebuild tissue. Does the patient have congestive heart failure or hypertension? Does the patient have peripheral vascular disease? So, if so, they will have decreased blood supply to the lower leg and therefore decreased oxygen and nutrients available for healing.
3. What medications is the patient currently taking? So steroids, NSAIDs, immunosuppressive medications, and chemotherapy all delay wound healing. Other medications may affect sleep, nutrition, and glucose levels, which will then in turn affect wound healing. Does the patient take medications as prescribed? So this is important because many times patients will admit to not taking medications. This is an opportunity for education and may also indicate a referral back to the physician.
4. Symptoms. Does the patient experience any pain? So, if so, is the pain at the ulcer site or is it in other areas? To assess pain, you can use the visual analogue scale and then assess pain at the wound site, and then also in any other surrounding areas. Severe pain may indicate infection or deep tissue destruction. Sudden onset of pain with oedema in the lower extremity may be a DVT. Is there any paraesthesia or anaesthesia? This can indicate neuropathy. Are symptoms relieved or worsened by elevation, rest, or activity? What increases and decreases pain or other symptoms? These questions can give you indication about the wound diagnosis and underlying cause, as well as help with treatment planning to reduce discomfort for your patient.
5. Occupation. This is important so that you know how the patient spends their day with respect to limb position, weight bearing, activity, and pressure. A person with a job that requires prolonged sitting may have difficulty elevating their limb. They may have increased pressure on the wound even when they're not weight bearing, I mean, even when they're not upright. And may not have the benefit of the calf muscle pump during ambulation to reduce oedema. A person with a job that requires prolonged standing, on the other hand, they may have issues with oedema due to dependency of their limb, or they may have difficulty adhering to an offloading protocol. They may experience more dressing slippage just from being up and around and the dressing gets loose.
6. Let's look at social history. So a few social questions are particularly relevant for wounds. Smoking history, use of alcohol or illegal drugs, average amount of sleep, all of which can affect their wound healing.
7. Basic nutrition, so you can ask about fruit, vegetable, protein consumption, water intake, any supplements that they're taking, processed or sugary foods, and then the number of meals that they're eating per day. This doesn't have to get specific, but it can give you a general idea about intake and nutrition and whether or not you may need a dietitian or a nutritionist involvement in their care.
8. What treatments have been used and what was the outcome? So is there any history of infection or delayed healing? This will provide you information about treatment planning because you will have an idea of what's been tried in the past, what's been successful, what's been unsuccessful.

Special Tests and Considerations

• In-patient Setting: So, if a patient is being seen in acute or long-term care facility, much of this information may be obtained from a chart review.
• If seen in an outpatient facility, the physician referral may contain this information. If not, you may ask the patient as part of your subjective.

So, has a wound culture been taken? If so, what kind? Was it a swab culture or a punch biopsy? What were the results? Was any treatment provided?

Have imaging studies such as X-rays or MRI (magnetic resonance imaging) been taken to look for osteomyelitis?

What about any other labs such as CBC (complete blood count) or white blood cell count, albumin, et cetera?

Has the patient received a referral or consult from any other healthcare providers? So did they already see a dietitian or diabetologist? Which ones, what tests, treatments, or education were provided at that time?

Patient's Input

• What are the patient's primary concerns at this time?
• What are their top goals? Okay, so what do they want to be working towards?
• What does the patient see as their biggest limitation to healing?
• And then how committed is the patient to making lifestyle changes? So you can ask this on a zero to 10 scale, with zero being not at all committed and 10 being a hundred percent committed.

Resources

• A list of questions to include in your subjective history will be put into the resources section for this course.
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1. numbered list
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