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 etiology is essential and will
guide interventions. Patients with combined ulcer
etiology require complete evaluation by a multidisciplinary
team.
- Assessment of leg may reveal edema, 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 edema.
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, edema, exudate,
odor, size (length, width, and depth), necrotic tissue,
granulation, epithelialization, and periwound skin
condition.
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