At the end of this chapter, the learner will be able to:
Perform a subjective evaluation of a patient with a wound.
Obtain the pertinent medical and surgical history from a patient or medical record.
Perform a wound assessment.
Determine the tests and measurements needed to establish a diagnosis and care plan.
Perform a review of systems for a patient with a wound.
Establish a wound diagnosis (for the four typical wound) etiologies.
Determine factors that may be inhibiting wound healing.
Recognize conditions that warrant immediate medical care and make appropriate referrals.
Establish goals and outcome measures for a patient with a wound.
The evaluation of a patient is designed to answer two primary questions: (1) Why does this patient have a wound? and (2) Why is the wound not healing? Answering these questions demands more than a wound assessment, although that is an integral part of the evaluation. It demands an evaluation of the patient, the medical history, and the four systems (integumentary, cardiopulmonary, neuromuscular, and musculoskeletal). Throughout the entire evaluation and treatment process, if the focus is on the patient and not just the wound, there will be a better understanding of why. In addition, the time spent obtaining this information will help develop trust and rapport with the patient, and will provide an opportunity to understand the patient goals. Attention to the patient allows the evaluator to recognize emergent or untreated conditions that warrant referral to either the primary care physician or an emergency care facility. Therefore, the focus of this chapter is on “the whole patient and not just the hole in the patient,” a phrase first coined by Carrie Sussman, a pioneer in physical therapy treatment of chronic wounds, but a phrase that has been used universally in the era of modern wound management.
Before the wound is uncovered and observed, there are questions that the evaluator can ask the patient (or care-giver) that are helpful in making a diagnosis and understanding why the wound is not progressing. A suggested list of questions is in TABLE 3-1 and is intended to serve as a guideline for initiating discussion with the patient. As the interview progresses, the evaluator will have additional and more pertinent questions relative to each individual patient. By the time the subjective history is completed, the evaluator will probably have a strong sense of the problems and is on the way to answering the question, why? There will also be an indication of the tests and measurements that are needed to make a definitive diagnosis (eg, laboratory tests, vascular screening, gait analysis, extremity girth).
Questions to Include in a Subjective Interview of a Patient with a Wound
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