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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: patients at risk experience decreased sensation of their legs and feet. Painless trauma may occur and be repetitive precipitating ulceration. Groups at high risk are those with diabetes, spinal cord injury, smoking history, advanced age, or Hansen’s Disease.
- General assessments: if the patient is diabetic, assessment of disease control is primary. Further assessment requires differentiation between neuropathic, arterial, and venous ulceration. Patients may have a combination ulcer aetiology (i.e., neuropathic and venous insufficiency).
- Assessment of leg requires evaluation of the ankle-brachial index. An index of <0.8 is an indicator of arterial involvement of some degree. However, diabetics with peripheral vascular disease my have falsely high results because of calcification of the arteries. These patients should be referred for noninvasive laboratory testing. oedema may be present.
- Assess for degree and type of pain (e.g. reduced response to touch). Neuropathic ulcers, without peripheral vascular disease involvement will have palpable pulses. Multidisciplinary evaluation and management is necessary in neuropathic ulcer care.
- 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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