2.3 History, Psychosocial Factors, Nutrition, and Pain

2.3 History, Psychosocial Factors, Nutrition, and Pain

Quick Answer: Interview the person and read the record: who actually changes the dressing, whether food and supplies are affordable, and what the pain is doing. Treat albumin as an inflammation marker, not a stand-alone malnutrition score. If the social situation cannot support daily wound work, the honest goal may be maintenance until access improves.

Outline items 010101 (knowledge of psychosocial factors), 010201 (knowledge of interview processes), 010203 (skill in performing the initial assessment), 010204 (skill in interpreting nutritional status), and 010205 (skill in interpreting pain) are how a CWCN turns a wound measurement into a plan a household can survive.

Interview plus record review

Start with the history of present illness: when the wound appeared, what the patient thinks caused it, prior treatments, what made it better or worse, and whether there were previous ulcers in the same place (scarred full-thickness skin will break down again with less insult). Ask about surgeries, radiation, grafts, bypass, amputation, and orthopedic hardware—they change etiology and infection risk.

Then leave the wound and ask the questions that decide adherence:

• Living situation — house, apartment, shelter, skilled nursing, unsheltered. Stairs, bathroom access, and whether the patient sleeps in a chair (edema, heel pressure) belong here.
• Who performs dressing changes — the patient, a daughter on night shift, a home-health aide three times a week, or nobody. A daily dressing ordered for someone who lives alone with severe arthritis is a paper plan.
• Economic and supply access — insurance, Medicaid prior authorization, ability to buy foam, compression, cleanser, and nutrition drinks. A perfect product the patient cannot obtain is not conservative care.
• Health literacy — teach-back on offloading and moisture, not a reading-level lecture. If the instruction sheet is written at a graduate level, the barrier is yours.
• Culture and beliefs — preferences about who may see the body, traditional remedies, fasting periods, and distrust of facilities. Work with the belief; do not ignore it.
• Mental status — delirium, dementia, depression, substance use. Cognition changes both consent for sharp debridement and whether a complex wrap will stay on.
• Family dynamics and caregiver capacity — burnout, competing jobs, elder abuse or neglect red flags, and whether the caregiver has their own health limits.

The initial focused assessment (010203) still includes the skin and wound exam, but the history tells you whether the findings are even actionable this week.

Nutrition: history first, labs second

Take a diet history: usual meals, protein sources, chewing and swallowing, dentition, nausea, taste change from medications, food insecurity, and who shops. BMI matters at both ends. Underweight and sarcopenia mean missing substrate for collagen. Obesity is not a protein surplus; it often coexists with malnutrition, diabetes, and moisture in folds. Look at the person: temporal wasting, clavicular hollows, thin skin, and conversely edema that can mask weight loss or reflect heart failure, venous disease, or low oncotic pressure.

Labs support; they do not diagnose nutrition by themselves:

Protein needs commonly discussed in wound care are about 1.25–1.5 g/kg/day for many adults with healing wounds who can tolerate that load. That range is a teaching anchor, not a one-size order. Renal disease, hepatic failure, and some palliative goals are contraindications or reasons to individualize downward. Calories must come with the protein or the patient will oxidize amino acids for energy. Involve dietitian services when the wound is large, the BMI is extreme, or swallowing is unsafe.

Pain: tool and type

If the person can self-report, use a numeric rating scale (NRS) or visual analog scale (VAS). If they cannot, use a nonverbal tool that matches the population: PAINAD for advanced dementia and FLACC (or similar observational scales) for patients who cannot use numbers. Do not skip pain assessment because dementia is present, and do not assume a PAINAD of 0 during a quiet rest period means dressing removal will be painless.

Separate four pain stories that change the plan:

1. Nociceptive wound pain — inflammatory, often worse with palpation or packing of dead space. Dressing choice, moisture balance, and treating infection help.
2. Neuropathic pain — burning, shooting, allodynia, common in diabetic neuropathy. The ulcer may be painless while the limb burns at night; offloading and neuropathic agents matter more than a thicker foam.
3. Ischemic rest pain — nocturnal foot or forefoot pain relieved by dangling, often with a punched-out ulcer and poor pulses. This is a vascular emergency-level history, not a request for a lidocaine gel as the complete plan.
4. Procedural / dressing-related pain — peaks during adhesive removal, irrigation, or packing. Treat with atraumatic dressings, soak-to-remove, time-limited premedication, and slower technique. High NRS only during changes with a quiet rest NRS is a dressing-procedure problem until proven otherwise.

Document baseline, procedural, and residual pain. Uncontrolled pain destroys adherence to compression and offloading, which then looks like noncompliance on the exam item.

When psychosocial barriers change the goal

Healing is not the only legitimate goal. If there is no safe person to do daily packing, no money for compression, active untreated psychiatric crisis, or the patient declines revascularization, a maintenance or palliative skin plan can be the ethical CWCN recommendation until those barriers move. That is not giving up; it is matching 010101 data to a plan the household can perform. Revisit the goal when caregiver capacity, housing, or supply access changes.

Scenario. Mr. Ortiz, 82, lives with a daughter who works two jobs. He has moderate dementia, BMI 17 with temporal wasting, a 6 cm sacral ulcer, A1C 9.8%, albumin 2.1 g/dL during pneumonia, and dressing-change NRS 7 with rest NRS 2. Medicaid has not released the prescribed foam. You do not treat the albumin as proof that protein drinks alone will close the ulcer, and you do not write a twice-daily complex packing schedule the daughter cannot keep. You arrange dietitian and social-work help, simplify to a dressing the aide can apply three times weekly, treat procedural pain, address glucose and pneumonia as inflammatory drivers of the low albumin, and document a maintenance-leaning plan until food, supplies, and caregiver time exist to support healing.