Registered Nurses' Association of Ontario

Comprehensive Health History

Review of Presenting Illness

  • Person’s previously healed pressure injuries (if any) and existing pressure injuries.
  • Cause of the person’s pressure injuries
  • Previous interventions/treatments (including their effectiveness or ineffectiveness) that the person has received from other health-care professionals.


Review of Psychosocial Status

  • The person’s psychological health, behaviour, and cognition (e.g., anxiety, depression, stress, ability to cope with one’s illness)
  • The person’s expectations, knowledge, and beliefs with respect to the interventions and outcomes of treatment (e.g., a person’s perception of a treatment on his/her quality of life).
  • The values and goals of care of the person and/or the person’s significant other(s), which can be influenced by his/her culture and ethnicity
  • The physical, financial, social, and emotional resources available to the person to support adherence to a management or treatment plan (e.g., availability and access to pressure redistribution support surfaces, lifestyle requirements and/or limitations, support with activities of daily living, emotional support)


Review of Co-morbid Health Conditions

  • An assessment of co-morbid conditions will identify factors that may interfere with pressure injury healing.
    • Wound healing is complicated by co-morbid conditions including but not limited to cancer, diabetes, stroke, heart failure, renal failure, and pneumonia.
    • People with diabetes, a suppressed immune system, an autoimmune disease, malnutrition, poor tissue perfusion, and hypoxia are at higher risk for localized infection.


Review of Allergies and Use of Medications and Other Substances

  • Review the medications that a person with a pressure injury uses to treat co-morbid conditions, including anti-rejection drugs, chemotherapy, and steroids, because these may impede pressure injury healing.
  •  Review the person’s allergies; food and wound care product sensitivities; use of alcohol, tobacco, and other substances (e.g., recreational drugs); and use of natural health products, vitamins, and mineral supplements, as these may also aff ect pressure injury healing or the treatment plan.


Review of Diagnostic Test Results

  • Complete blood count (e.g., haemoglobin, hematocrit, white blood cell count, absolute lymphocyte count, red blood cell morphology);
  • Iron profile (e.g., ferritin, serum iron, percentage saturation, total iron binding capacity);
  • Inflammatory markers (e.g., C-reactive protein, erythrocyte sedimentation rate);
  • Endocrine factors (e.g., fasting or random glucose, haemoglobin A1C, thyroid function tests); and
  • Albumin: Albumin is a poor indicator of nutritional status; it should be used as a prognostic factor for inflammation, which can increase the risk of malnutrition by increasing a person’s metabolism.
Clinical Management
Assessment and Management of Pressure Injuries for the Interprofessional Team, Third Edition
Point of Care Resources