1.7 Psychosocial History, Cognitive Status, and Functional Assessment

Psychosocial History, Cognitive Status, and Functional Assessment

Two separate blueprint objectives — 1.04 (psychosocial history) and 1.08 (cognitive and functional status) — cover the patient factors that determine whether an otherwise perfect wound plan will actually happen. A four-layer compression system is worthless if the patient cannot get to the clinic to have it reapplied. Twice-daily dressing changes are worthless if the patient lives alone and cannot reach their own sacrum. The exam tests this as a plan-feasibility question: given these patient circumstances, which intervention is realistic?

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1. The Psychosocial History (Objective 1.04)

NAWCO names six elements explicitly.

Occupation

Occupational history is etiologic, not just biographical:

• Prolonged standing or sitting — nurses, teachers, hairdressers, retail and factory workers, long-haul drivers — sustains ambulatory venous hypertension and is a direct risk factor for venous leg ulceration.
• Kneeling and squatting trades produce prepatellar pressure and friction injury.
• Heavy manual work determines whether a compression garment or an off-loading boot can be worn during working hours, which in turn determines whether the patient will wear it at all.
• Employment also drives insurance status, sick-leave availability, and whether attending a weekly clinic appointment costs the patient a day's wages.

Living Situation

Ask who else is in the home, what floor the bedroom is on, and whether there are stairs, a working refrigerator for supplies, running hot water, and reliable electricity for a negative pressure pump. A patient who is homeless or in unstable housing cannot keep a dressing clean and dry, and the plan must be simplified accordingly — a longer-wear, all-in-one dressing beats a technically superior product that requires sterile daily changes.

Culture

Culture shapes dietary patterns relevant to protein intake and glycemic control, norms about modesty and who may examine which body part, expectations about family-centered rather than individual decision-making, beliefs about the meaning of illness, and the acceptability of specific products (for example, porcine-derived collagen or alcohol-containing preparations). Ask rather than assume; cultural humility means treating the patient as the authority on their own culture.

Environment

The physical environment includes the home, but also the care setting. Is there space to store boxes of supplies? Is there a caregiver present at the time the dressing must be changed? Is there transportation to the wound clinic? Is there a pharmacy that stocks the prescribed product? Food insecurity belongs here too — a protein target of 1.25 to 1.5 g/kg/day is not achievable on an unreliable food supply.

Gender Identity

Recording the patient's name in use and pronouns, and using them consistently, is part of a complete assessment. It also has direct clinical relevance: gender-affirming surgical sites, chest binding (which can cause pressure and friction injury and impair chest wall movement), tucking practices, and hormone therapy effects on skin quality and clotting risk are all wound-relevant and will not be volunteered unless the clinician creates a safe opening.

Support Systems

Identify who will realistically perform care: a spouse, an adult child, a paid aide, a home-health nurse, or nobody. Assess the capability and burden of that person — an 80-year-old spouse with arthritis and poor eyesight may be willing but unable. Screen for caregiver fatigue; an exhausted caregiver is a predictor of readmission.

Reframing "noncompliance": NAWCO's own objective 1.05 lists "noncompliance" among the factors to assess, but the exam-appropriate reasoning is to identify why. Cost, transportation, literacy, pain, depression, dexterity, competing caregiving duties, and simple misunderstanding explain the overwhelming majority of missed treatments. Objective 3.04 makes this explicit by asking you to evaluate barriers and reasons, not just adherence itself.

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2. Cognitive Status (Objective 1.08)

Orientation and screening

Document orientation to person, place, time, and situation. Where impairment is suspected, brief validated screens are used: the Mini-Cog (three-item recall plus a clock-drawing test, taking about three minutes) and the MMSE or MoCA for a fuller picture. An acute change in attention and a fluctuating course suggests delirium, not dementia — delirium is a medical emergency with a treatable cause, and in a wound patient the cause is frequently infection, dehydration, or uncontrolled pain from the wound itself.

Decision-making capacity versus competency

This distinction is examined repeatedly and is easy to get backwards:

A patient with dementia is not automatically incapable of consent. Capacity must be assessed for the specific decision at hand, and a patient who retains capacity may refuse treatment even when the clinician disagrees.

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3. Functional Status (Objective 1.08)

Basic ADLs — the Katz Index

Six activities: bathing, dressing, toileting, transferring, continence, and feeding. Loss of transferring and continence are the two most directly wound-relevant: a patient who cannot transfer independently cannot offload, and incontinence drives moisture-associated skin damage.

Instrumental ADLs — the Lawton scale

Eight activities: shopping, food preparation, housekeeping, laundry, transportation, medication management, financial management, and telephone use. These predict whether a patient can obtain supplies, get to appointments, and manage a medication schedule.

Mobility, dexterity, and reach — the wound-specific additions

Generic ADL scores miss the questions that actually decide the dressing plan:

• Can they see the wound? A sacral or posterior heel wound is invisible to the patient. A plantar ulcer requires a long-handled mirror or a caregiver.
• Can they reach it? Test it rather than assume. Limited hip flexion, obesity, a frozen shoulder, or a spinal fusion may make self-care physically impossible.
• Can their hands do it? Rheumatoid arthritis, tremor, neuropathy of the fingers, or reduced grip strength can prevent a patient from opening a sterile package, cutting a dressing to size, or donning a class 3 compression stocking — which is one of the most common reasons compression fails. A donning aid, a lower-class garment worn correctly, or a wrap system with hook-and-loop closures beats a prescribed stocking that stays in the drawer.
• Can they reposition? Independent bed mobility is the difference between a turning schedule that the patient partly self-manages and one that depends entirely on staff.

Putting it together: the assessment output is not a score, it is a modified plan. Poor dexterity plus a venous ulcer means a wrap system rather than a stocking. Living alone plus a sacral wound means a seven-day-wear foam rather than daily gauze. Cognitive impairment plus a limb dressing means a tubular retention bandage the patient is less likely to remove. Objective 1.08 is assessed on the exam by asking which plan survives contact with the patient's real life.