The examination of an open wound often focuses on the use of tests and measures, with perhaps some attention paid to a systems review. However, one important component that can sometimes be overlooked in a busy practice is a focused history of both past and current factors related to the current presentation of the patient. Information learned from the patient history can often be pivotal in understanding the present condition, and can frequently help direct management strategies.
Patient History Necessities
A patient history can be obtained directly from the patient, or from medical records, family, caregivers, or nursing staff. The patient history can usually be broken down into the following areas:
- General demographics – Many disease processes vary according to age, gender, and ethnic background. It is therefore important to document these characteristics in order to tailor treatment appropriately.
- Lifestyle and functional status – A patients living arrangements and employment status can have a bearing on the most appropriate course of action. For example, an intervention that is appropriate for a patient who is supported at home by a caregiver may not be suitable for somebody who lives alone, or who has to go out to work.
- Past and current medical conditions – The presence of conditions such as cardiopulmonary diseases, diabetes, cancer or HIV must be identified before appropriate treatment can be introduced. It is also important to establish current medications to ensure new treatments are compatible.
- Past and current wound history – Information about a past or current wound can provide valuable insights into the etiology, prognosis and healing potential of a current wound.
By understanding the full patient history, the wound care specialist is able to more fully understand the current wound presentation and to tailor interventions in the most appropriate way.
Gaining wound certification can be a highly effective way to learn more about all aspects of wound management, including the importance of a full patient examination and patient history. Wound certification demonstrates a commitment to the area of wound care, helps in day-to-day wound management tasks, and improves career prospects.
Learn More With Our Wound Care Education Options
Interested in learning more about wound care certification? Browse through our wound care certification courses for information on our comprehensive range of education options to suit healthcare professionals across the full spectrum of qualifications and experience.
- Hess CT. Assessing the Total Patient. Advances in Skin & Wound Care 2008;21:1.
- Myers BA. Wound management principles and practice. 2nd ed. Upper Saddle River, NJ: Pearson; 2008.
- Posthauer ME. The Value of Nutritional Screening and Assessment. Advances in Skin & Wound Care 2006;19:388-390.