Wound Assessment- Gathering a History

wound assessment history

Wounds are more than the sum of their parts- they are caused by a myriad of factors that come together to create the setting in which a wound is permitted to form and heal. As such, clinicians must consider both internal and external factors that influence wound formation and (hopefully) wound healing.

In this segment, we’ll look at some of the information that clinicians should consider before the wound is even viewed, such as patient history, demographics and lifestyle/functional status. Why do these matter? All of the information gathered allows the clinician to determine the factors that may have contributed to creating the wound and helps the clinician to formulate a treatment plan.


A thorough patient history can provide the clinician with a wealth of information. It includes not only the basics needed for record keeping, such as the patient’s name, address and health care insurance information, but also social and employment history, living environment, health habits both positive and negative, family history and general medical history. This may sound like a lot of information (and it is), but gathering this information is important to determining how best to help the client.

Demographic information

Besides learning what the patient likes to be called, demographic information can provide clues that may prove important in care planning. Age, gender, ethnicity/race, level of education and the primary language spoken by the patient are all important. Consider how the clinician might approach care of a patient’s wound with a patient who is elderly, speaks little English and has a low level of education. Obviously, in this scenario, teaching will need to be simple and must take into account the patient’s ability to understand the information provided, as well as the patient’s ability to care for himself and his wound. Now consider the approach to care if the patient is highly educated, speaks English and is young and well able to care for himself. As you can see, the clinician’s approach to these two patients might be quite different. The first client will require greater support and resources than the second.

Lifestyle/functional status

Lifestyle and functional status are also important considerations when providing wound care and education. For example, the following questions are important to ask:

  • Does the patient live alone, or are others present who can assist with care?
  • Does the patient work? Were they able to work prior to developing the wound? If they can’t work, how has this affected their economic status?
  • Can the patient perform ADLs and IADLs, or do they require assistance with basic personal and household activities?
  • Does the patient have any health habits (i.e. drinking alcohol, smoking or taking illegal drugs) that may impact their ability to care for themselves and their wound?
  • Does the patient have sensory impairment that will make it difficult to care for his wound (i.e. vision problems, inability to sense pressure or pain)?

Living Environment

Living environment is also a consideration. Where does the patient live? If the patient is in hospital, where will they be discharged to? Does the patient have stairs to climb? Does the patient have any assistive devices such as bathroom bars or a recliner? Is there room for the patient to maneuver with crutches, a wheelchair or a walker? All of these factors can speed or impede healing for the patient, for example, with a painful ulcer of the lower extremity.

General Health Status

The general health of the patient can help the clinician to plan care. Gathering information about sleep patterns, nutrition/eating patterns, cognition, psychological status (i.e. depression), and general functioning can be of immense importance to wound healing. The patient who eats a poor diet, is depressed and has dementia will be a greater challenge in terms of wound care than a young patient in good physical condition with no barriers to healing.

As can be seen, holistic care is essential in wound care management. It’s not enough to simply examine a wound, decide on a dressing and ask the patient to come back for a wound check in three days. Rather, the astute clinician gathers as much information as possible regarding the patient and his life in order to formulate a care plan that takes all of these factors into account and provides the best chance of healing. In part two of this series, we will look at the patient’s past and current medical and wound history.

If you enjoyed this piece and want to learn more about wounds and wound certification, take the next step in your career and become wound care certified.  Getting your wound certification will allow you to leap ahead of colleagues and show your value in your workplace.


Meyers, B. (2008). Wound Management: Principles and Practice. 2nd edition. Pearson Prentice Hall. Upper Saddle River, New Jersey. pg. 41-44.

Oxford Handbook of Clinical Skills in Adult Nursing (2009). Oxford University Press. Chapter: Wound Care. Published online August 2010.

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