Performing a comprehensive patient assessment is an essential first step toward healing a chronic skin condition or wound. After the clinician has assessed the patient, identified any underlying conditions affecting healing, performed a complete assessment of the patient’s nutrition status, performed the proper tests to provide an accurate diagnosis of the underlying problem, assessed the patient’s knowledge of the disease, and documented all factors that affect the learning needs of the patient, a complete skin and wound assessment can be completed.
The assessment is set in motion with a one-on-one discussion between the patient or caregiver and clinicians who have cared for the patient’s skin and wound. Understanding the patient’s past and current family, social, and medical history may provide important insight into why the wound isn’t healing. Clinical interventions will vary according to the assessment.
Checklist: Obtaining a History
A thorough review of the patient’s medical history, laboratory tests, medications, and diet can help the clinician determine the cause of the skin condition or wound. Chronic wounds, for example, can be caused by a multitude of different diseases. To obtain a patient’s history, follow these steps:
✓ Review the patient’s medical history, including allergies, laboratory studies, radiologic studies, vascular studies, medications, past illnesses, surgical procedures, and other pertinent facts related to the patient’s illnesses and problems. Ask the patient if his/her skin’s appearance changes with the seasons.
✓ Review the patient’s family history, paying particular attention to parents, siblings, grandparents, and natural children and detailing the age and general health information of living relatives, the death and cause of death of all deceased family members, and any chronic diseases that occur in the immediate family. This information will alert you to the presence of inherited or congenital conditions or diseases.
✓ Review the patient’s social history, including age-appropriate information regarding past and current activities, such as marital status, living arrangements, current employment and occupational history, sexual history, level of education, and use of drugs, alcohol, or tobacco.
✓ Ask about the patient’s bathing routines and about the different soaps, shampoos, conditioners, lotions, oils, and other topical products he/she uses routinely. Any such products may lead to changes in skin, appearing as xerosis, pruritus, wounds, rashes, or a change in skin color.
✓ Obtain a list of past and current medications and dressings, including all medications and dressings that have been used, have been effective, or have failed.
✓ Review previous treatments, dressings, drugs, and adjunctive modalities (such as physical therapy, skin replacements, and growth factors) and determine their effectiveness.
✓ Review all laboratory, radiology, and vascular studies that have been performed.
✓ Review the patient’s nutrition status and supportive therapies.
For the patient who has a wound:
✓ Review all clinician consultations related to specialty management programs for skin and wound care.
✓ Review (if indicated) all support surfaces and positioning devices used to manage the patient’s tissue load.
✓ Review (if indicated) any use of devices, such as compression stockings, custom shoes or braces, and assistive devices.
✓ Assess the patient’s knowledge of the disease and document all factors that affect learning needs.
These findings will provide the clinician with a strong foundation upon which to manage the patient’s skin and wound. An incomplete assessment may delay the skin- or wound-healing process.
Read previous articles in “Advances in Skin & Wound Care” by Cathy Thomas Hess in the link.
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Cathy is Chief Clinical Officer for WoundExpert® and Vice President at Net Health, and in addition to being the MIPS Clinical Consultant for WoundExpert. She gained over 30 years of expertise in various acute care, long-term care, sub-acute care facilities, home-health agencies, and outpatient wound care department settings. Cathy is the author of Clinical Guide to Skin and Wound Care (also translated into Italian and Portuguese) – Eighth Edition published in September of 2018.