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 section 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.
Following 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).
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 and 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.