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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 etiology (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.
Edema 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, edema, exudate,
odor, size (length, width, and depth), necrotic tissue,
granulation, epithelialization, and periwound skin
condition.
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