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The following provides a guideline for clinical assessment. Assessments must be done at regular intervals and are used to drive treatment decisions.
- Assessment of risk or contributing factors: smoking, diabetes, increased age, atherosclerosis. Other associated factors include arthritis, anaemia, CVA, vascular procedures/surgeries, hyperlipidemia, hypertension, pressure, and friction.
- General assessments: differentiation between arterial, venous, and diabetic aetiology is essential and will guide interventions. Patients with combined ulcer aetiology require complete evaluation by a multidisciplinary team.
- Assessment of leg may reveal ischaemic skin changes, purpura, atrophy of subcutaneous skin, thick toe nails, hair loss on lower extremities, taut, shiny, dry skin, pitting, or dependent oedema. An ankle-brachial index of <0.8 may indicate ischaemia and should be evaluated further. Pain may be severe and debilitating with intermittent claudication, rest pain, or nocturnal pain.
- Assessment of nutrition, previous ulcer care (if applicable), level of understanding, compliance in care, and learning style.
- Assessment of wound: infection, oedema, exudate, odour, size (length, width, and depth), necrotic tissue, granulation, epithelialization, and periwound skin condition.
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