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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: history of deep vein thrombosis, previous leg ulceration, obesity, pregnancy, leg trauma, smoking, CHF, vascular procedures or surgeries, reduced mobility, family history, advanced age.
- General assessments: differentiation between venous, arterial, 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 oedema, varicosities, healed ulcer sites, an inverted "bowling pin" shape to the leg. A palpable peripheral pulse is generally present but may be difficult to assess due to oedema. The ankle-brachial index is usually >0.8 and pain is mild to moderate and improved by elevation. Frequently hypersensitive to topical agents. Skin temperature normal.
- 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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