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, anemia, CVA,
vascular procedures/surgeries, hyperlipidemia, hypertension,
pressure, and friction.
- General assessments: differentiation
between arterial, venous, and diabetic etiology is essential
and will guide interventions. Patients with combined ulcer
etiology require complete evaluation by a multidisciplinary
team.
- Assessment of leg may reveal ischemic skin changes,
purpura, atrophy of subcutaneous skin, thick toe nails,
hair loss on lower extremities, taut, shiny, dry skin,
pitting, or dependent edema. An ankle-brachial index of
<0.8 may indicate ischemia 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, edema, exudate, odor,
size (length, width, and depth), necrotic tissue, granulation,
epithelialization, and periwound skin condition.
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