by Mary Ellen Posthauer RDN, CD, LD, FAND
by the WoundSource Editors
A myriad of factors need to be addressed when evaluating a patient with a wound. A thorough patient history, including previous wounds, surgeries, hospitalizations, and past and existing conditions will help guide your clinical assessment, in addition to a number of questions specific to the wound(s) being assessed. Following is a list of general questions to ask when evaluating a wound care patient. (Please note that this list is not comprehensive and is intended only to serve as a guide):
- What type of wound is it?
- Where is the wound located?
- What size is the wound?
- Has the etiology of the wound been determined and addressed?
- Has a biopsy been performed on the wound to rule out infection, inflammatory disease or cancer?
- Is there adequate blood flow to the wound?
- How long has the wound been present?
- Has the patient's pain increased?
- Has the size of the wound increased since last assessed?
- Is the wound tunneling or undermining?
- Is bone exposed?
- Is there an odor present?
- Is there exudate from the wound? If so, how much?
- Is there edema of the wound tissue?
- Is there necrotic tissue present in the wound? If so, how much?
- Is there granulation tissue present in the wound? If so, how much?
- Is there epithelial tissue present in the wound? If so, how much?
- What is the color of the wound tissue?
- What do the wound edges look like?
- Is there induration and erythema of the periwound tissue?
- How is the patient's nutritional intake?
- How is the patient's fluid intake?
- Is the patient taking supplements?
- What are the patient's albumin and pre-albumin levels?
- What is the patient's medical and surgical history?
- What medications is the patient currently taking?
- What is the patient's fasting blood glucose and HgA1C?
- What is the patient's complete blood count?
- Does the patient smoke, consume alcohol, or use illegal substances?
- What types of wound dressings have previously been used on the wound?
Comprehensive Wound Assessment for Improved Outcomes
Always refer to your facility's intake and assessment protocol for thorough assessment and documentation of the patient and the patient's wound. Gathering answers to these questions and taking a holistic approach to assessing the patient, not just the wound, will support treatment options and offer early identification of factors that may become barriers to wound healing.
Editor's Note: This blog has been adapted from the article, "Top 30 Questions to Assess both a Patient and a Wound," by Jackie Brace, PhD, RN-BC, CWOCN, APRN-B, published to WoundSource.com on October 24, 2008. This article has been expanded and updated for comprehension by Kestrel Health Information staff editors.