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HOLISTIC ASSESSMENT
JCN supplement
2018,Vol 32, No 4
5
vascular assessment. Diagnosing
the aetiology of an ulcer/wound
during assessment helps to signpost
clinicians towards the correct wound
treatment regimen. There are many
areas to explore during this
holistic assessment.
Healthcare professionals must
consider medical, psychological
and social factors that can have an
impact on wound healing, rather
than look at a wound in isolation
(
Table 1
). For example, if a patient
has a poor diet, they will not be
receiving adequate nutrients to
aid tissue healing. History-taking
must be comprehensive, with clear
consideration and exploration of
patients’past and current medical
history, current self-care and lifestyle.
During the assessment stage, it is
also important to ascertain how
the wound is affecting the patient’s
activities of daily living and gain an
understanding of their expectations
and goals to enable individualised
patient-centred treatment plans.
Medical status and comorbidities
should be reviewed, taking into
consideration anything that will
contribute to further damage of
venous or lymphatic systems, such as
diabetes, peripheral vascular disease
or autoimmune diseases. Healthcare
professionals should enquire about
any previous deep vein thrombosis
(DVT) or surgery to the legs, chronic
oedema, skin conditions, or any
previous history of ulceration. It is
also important to ask if there has
been a repeated pattern of ulceration,
or if this is the first occasion, and
whether there is a family history
of ulcers.
Patients’regular medication
should be reviewed, including
questions about any over-the-
counter/self-issued, in case any
of these medications might have
an effect on wound healing.
Medications, such as corticosteroids
and non-steroidal anti-inflammatory
medications, have been linked to
an increase in wound infection and
delayed healing (Anstead, 1998),
due to the effect that they have on
the inflammation process. Cytotoxic
agents, such as methotrexate,
chemotherapeutic agents and
immunosuppressants, such as
azathioprine, can all have a potential
negative impact on wound healing
(Levine, 2018).
Extrinsic factors, such as lifestyle
choices, i.e. being sedentery,
overweight or having a poorly
balanced diet, can significantly impair
wound healing and increase the risk
of venous insufficiency. Healthcare
professionals should also review the
patient’s mobility — do they sit for
lengthy periods which may result
in venous insufficiency, or do they
require help or walking aids
to mobilise?
The history of the wound should
also be reviewed, considering when
it developed and if there are any
predisposing causes, such as trauma
or surgery. Documenting wound size,
tissue type present, condition of the
periwound skin, and if there are any
signs of infection are also vital.
Details about previous dressing
choices/treatments for both the
current wound and any previous
ulcers, and whether they aided
healing and were acceptable to
the patient, need to be ascertained
to help with future care planning.
Establishing if compression therapy
has been previously used (e.g. hosiery
kits, wrap systems, etc) and, most
importantly, if the patient was able
tolerate the treatment is vital. Within
an holistic approach, the patient’s
choice/opinion should be considered,
and so healthcare professionals
need to gain an understanding of
previous issues with concordance
with treatment and to ensure that
they keep the patient central to the
decision-making process (Stanton et
al, 2016).
Documentation of smoking
status is vital, as this can impair
wound healing due to nicotine
being a vasoconstrictor which
adversely affects the microcirculation
(Siverstein, 1992).
Visual inspection of the lower
limb provides a good insight as to
the presence of venous disease,
such as varicose veins, oedema or
haemosiderin staining (Harding et
al, 2015), while understanding the
patient’s vascular status enables
clinicians to assess whether an ulcer
is venous or arterial in origin, or a
combination of both, i.e. a mixed
venous/arterial ulcer (Vowden and
Vowden, 2001).
Measuring ankle brachial pressure
index (ABPI) is widely used as a
non-invasive method of testing
the extent of peripheral arterial
disease (PAD) in the lower limbs.
In simple terms, it compares blood
flow in the arms to that of the legs
and a ratio is composed (Al-Qaisi
et al, 2009). This index is the most
commonly taught assessment tool
for vascular assessment and is seen
as a mandatory part of assessment
for leg ulcer patients before starting
compression therapy in primary care
(Vowden andVowden, 2001).
Table 1:
Factors to consider during
wound assessment
(Carville, 2005)
Underlying disease
Vascularity
Nutritional status
Immune status
Obesity
Disorders of sensation or movement
Psychological state
Radiation therapies
Drugs — prescribed, recreational
and/or alternative
Allergies and/or sensitivities
Local factors:
Hydration
Wound management
Pressure, friction and shear forces
Foreign bodies
Wound infection
›
Practice point
The outcome of comprehensive
holistic assessment should provide
an overview of the patient’s
presenting medical condition, the
cause, duration and status of the
wound, along with any factors
that might impede wound healing
(Anderson and Hamm, 2012).