Presenting Complaint and Recent History

As with any assessment it is important to start by recording the presenting complaint – the reason the patient has sought, or been referred for treatment. In the case of wound assessment, the presenting complaint will usually be the patient’s wound. Wound assessment is discussed in detail in the second part of this module.

A brief history of the presenting complaint should also be recorded, as this will give clues as to the aetiology of the wound.

Full Medical History

Following on from the presenting complaint, the patient’s full medical history should be recorded. This information will act as a guide as to which investigations should be undertaken.

Wound healing can be delayed by systemic factors that bear little or no direct relation to the location of the wound itself. These include age, body type, chronic disease, immunosuppression, nutritional status, radiation therapy and vascular insufficiencies (Hess, 2011).

Social History

The World Health Organisation [WHO] (2003) has recognised that poor social and economic circumstances affect health throughout life. Life expectancy is shorter and diseases are more common, the further down the social ladder within society.

Socioeconomic factors can be big stressors for patients. The majority of patients want their wounds to heal but can often feel restricted by their social and economic status. Factors such as limited access to transportation, job loss, insufficient monthly income and lack of support or carer availability have an impact that can affect wound healing. (Wound Source 2018)

There are other social factors that need to be considered when deciding upon a patient’s treatment plan. A plan of care must be acceptable to the patient and fit in with their lifestyle, so they comply with their treatment. Family history must also be recorded, as there are a number of medical conditions that have strong familial links. A holistic assessment of each patient must be conducted and documented.

Baseline Observations

Physiological observations are essential to establishing that patients in hospital are safe and that healthcare professionals are cognisant of the patient’s health status (NICE 2007, NPSA 2007).

Baseline observations should be taken as part of a patient assessment. The aim of taking sequential observations (vital signs) is to identify change in the patient’s condition and signs of serious illness or deterioration. The observations should be obtained promptly and documented accurately e.g. a rise in body temperature that might denote an infection or a reduction in the amount of fluid taken that might indicate a general decline. (RCNi 2019). Furthermore, they are important for measuring the success of treatment and how an illness is progressing. As clinicians, we should be observing the patient at all opportunities to look for these changes.

An experienced practitioner may consider sending the patient for further tests and investigations depending on their medical history and the suspected wound type. It is important to note that not all changes will be captured by the above observations. A general viewing of the patient, knowing what their normal is and noticing any changes however minor, is a valuable tool that can be applied to the overall patient management plan.

As a general rule, the following should be taken;

Blood Pressure – High blood pressure that is undiagnosed or ineffectively managed can lead to damage to the heart and blood vessels, which can impact blood flow. This may translate to decreased nutrients and oxygen being delivered at the cellular level, which may impede wound healing. (Wound Educators 2014)
Hypotension, a low blood pressure, is an important risk factor and significant in assessing acute illness severity. It may signify circulatory compromise due to sepsis, cardiac failure, cardiac rhythm disturbances, volume depletion, central nervous system (CNS) depression, hypo-adrenalism and or the effects of blood pressure medication.
Some people may have a naturally occurring low systolic blood pressure (< 100mgHg) that might be noted if they are well and other physical factors are normal. Previous medical records and observations should be referred to for information (RCP 2017).

Pulse – The measurement of heart rate is an important indicator of a patient’s clinical condition.
Tachycardia may be indicative of circulatory compromise due to sepsis or volume depletion, cardiac failure, pyrexia, or pain and general distress. It may also be due to cardiac arrhythmia, metabolic disturbance, e.g. hyperthyroidism, or drug intoxication, e.g. sympathomimetic or anticholinergic drugs.
Bradycardia is also an important physiological indicator. A low heart rate may be normal with physical conditioning or as a consequence of medication, eg with beta-blockers. However, it may also be an important indicator of hypothermia, CNS depression, hypothyroidism or heart block. (RCP 2017)

Respiratory – Respiratory rate. (RR). The normally accepted range for an adult is 12-20 breaths/min, however, this can vary according to the patients’ age and medical condition. It is generally accepted that a rate of >25 breath/min or increasing RR can indicate that a patient may deteriorate suddenly. Likewise, a rate of<8 breaths/min, or a decreasing RR can also signify deterioration. (Kelly 2018)

Oxygen Saturation – It can be a powerful tool for the integrated assessment of pulmonary and cardiac function. The technology required for the measurement of oxygen saturation, e.g. pulse oximetry, is now widely available, portable and inexpensive.
Pulse oximetry can often be used to confirm practitioners’ clinical view. However, it should be noted that this can be misleading and inaccurate in some patients, for instance, those with anaemia, arrhythmias, poor peripheral perfusion and exposure to carbon monoxide. Used in conjunction with the appropriate clinical judgement and combined with respiratory rate, signs of increased effort in breathing, colour and recently acquired confusion there is potential to consistently provide valuable information on the patient’s condition and progress (Boulanger &Toghill 2009)

Temperature – A body temperatures outside normal ranges may be symptomatic of underlying diseases or clinical deterioration. Maintaining a body temperature within normal ranges aids in optimising the metabolic process and bodily functions.

Pyrexia – Is an elevated body temperature (> 38°C). This is usually caused by infection or inflammation. Pyrexia is also known as fever or febrile response.

Hyperthermia – This occurs when the body produces and/or absorbs more heat than it can dissipate (> 40°C) e.g. heat stroke

Hypothermia – The body temperature drops below a safe level (<35°C) it can be caused by environmental factors, metabolic complications, disease processes, or can be medically induced. (McCallum &Higgins 2012, RCH 2020)

Full Blood Count (FBC) – The FBC is used as a broad screening test to check for such disorders as anaemia, infection, and many other diseases. It is important that as a healthcare professional there is an understanding of the clinical significance of these blood results to enabling identification of abnormalities and the appropriate response.

C-Reactive Protein (CRP) – CRP is produced by the liver and Its level rises when inflammation is present. A high-sensitivity C-reactive protein (hs-CRP) test may be used in some cases to evaluate the risk of developing coronary artery disease.

Urea & Electrolytes (U&E) – Provides several characteristics of health e.g. volume of the blood and its pH. It conveys essential information on renal function, primarily excretion and homoeostasis. Creatinine levels are a major factor in determining renal health.

Sepsis – Please see the next topic for more information.