Health Services for South West
| |Client Name: |
|South West Regional | |
|Wound Care Toolkit: |Address: |
|Interdisciplinary Lower Leg Assessment Form | |
|Instructions for use: Competent/ Proficient/ Expert level HCP to complete if lower |Assessment Date: |
|leg ulcer present or risk of ulcer is suspected. |NOTE- This can be used as an electronic Document, made into an Interactive PDF|
| |or used as a paper document, in which case it would need to have Client name |
| |and signatures on each page. |
The red recommendations at the end of each section are ACTION indicators.
|a. ULCER OR PRE-ULCEROUS CONDITIONS |
|Right Leg |Left Leg |
| |History of previous ulcer? Years: | | |
| |Locations: | |Locations: |
| |Skin stretched with imminent breakdown. | |Skin stretched with imminent breakdown. |
| |Serous weeping from leg without signs of ulceration. | |Serous weeping from leg without signs of ulceration. |
| |Sub-keratotic hemorrhage under callus. | |Sub-keratotic hemorrhage under callus. |
| |Probes to bone | |Probes to bone |
|Comments: |Comments: |
|ACTION: Consider presence of osteomyelitis if probes to bone in DFU (70-90%), pressure ulcer or venous ulcer |
|b. LEG PAIN (SEE SECTION d. FOR SYMPTOMS OF NEUROPATHY) |
|Right Leg | Left Leg |
|Other Symptoms |Venous Symptoms |
|ACTION: See Section B.5 Wound Pain Assessment Tools for pain >4/10 |
|Refer to Pain Specialist or PT to address pain control. |
|c. FOOT DEFORMITIES, NAILS AND FOOTWEAR |
|Right Foot |Left Foot |
|Foot Deformities: | |
| hammer toes | claw toes |
|Nails: | |
| thick | yellow |brittle |fungus |
|Footwear: |
|orthotics not being worn at all times, indoor or out inappropriate footwear |
|presence of pressure areas Location: |
|d. TEST FOR NEUROPATHY Applicable Not Applicable |
|Right Foot | Left Foot |
|Sensation Score: /10 |Sensation Score: /10 |
|10- point Monofilament Neuropathic Assessment - Indicate with a + or - the presence or absence of sensation |
| |
| |
|[pic] |
| |
| |
|Sensory: |burning |tingling |crawling |
| |numbness | | |
|Sensory &/or Autonomic |charcot |acute charcot |Sensory &/or Autonomic |charcot |acute charcot |
|e. DIABETIC FOOT RISK CLASSIFICATION SYSTEM: The International Working Group Original and Modified Criteria 2010 |
|Applicable Not Applicable |
|Right Foot |Left Foot |
| 0 | 1 Loss of | 2a Loss of | 2b | 0 | 1 Loss of | 2a Loss of | 2b |
|Normal- no |protective sensation|protective |Peripheral |Normal- no |protective sensation|protective sensation|Peripheral arterial|
|neuropathy | |sensation and |arterial disease |neuropathy | |and deformity |disease |
| | |deformity | | | | | |
| 3a Previous history of DFU | 3b Previous history of amputation | 3a Previous history of DFU | 3b Previous history of amputation |
|Comments: |Comments: |
|f. The University of Texas Staging System for Diabetic Foot Ulcers (only for clients with Diabetic Foot Ulcer) |
|Applicable Not Applicable |
|Stage |Grade 0 |Grade I |Grade II |Grade III |
|A |Pre- or post-ulcerative lesion |Superficial ulcer, not involving |Ulcer penetrating to tendon or |Ulcer penetrating to |
| |completely epithelialized |tendon capsule or bone |capsule |bone or joint |
|B | Infection | Infection | Infection | Infection |
|C | Ischemia | Ischemia | Ischemia | Ischemia |
|D |Infection & Ischemia |Infection & Ischemia |Infection & Ischemia |Infection & Ischemia |
|Score: Grade______ Stage_____ |
|Actions: |
|Refer to a foot specialist (chiropodist, podiatrist, pedorthist etc.) for those with a DFU present and/or loss of protective sensation for pressure redistribution |
|devices |
|Refer to OT if underlying pressure and/or surface concerns. |
|Consider referral to a PT or other qualified health care professional for adjunctive therapy if healing has not |
|occurred at the expected rate in spite of best practices x 4 weeks (see Section 13 for details). |
|Consider biologically active agents if healing has not occurred at the expected rate in spite of best practices x 4 weeks (see Section 13 for details). |
|g. EDEMA (IF PRESENT) |
| Right Leg | Left Leg |
|Date of onset: | |Date of onset: | |
|Asymmetrical with contra-lateral limb |Asymmetrical with contra-lateral limb |
|Location: |toes |
|Pitting: |1+ = 0 - ¼” |2+ = ¼” – ½” |3+ = ½ - 1” |
| |non-pitting |brawny induration | |non-pitting |brawny induration |
|Measurements: |Measurements: |
|Midfoot= | cm |
|Adherent to wearing compression stockings in past |Adherent to wearing compression stockings in past |
|Age of current compression stockings: |Age of current compression stockings: |
|h. LYMPHEDEMA ASSESSMENT *NB- individuals can have symptoms of both venous & lymphedema or lymphedema & lipedema |
|Right Leg |Left Leg |
| Positive Stemmer’s sign - A thickened skin fold at the base of the second toe | Positive Stemmer’s sign - A thickened skin fold at the base of the second toe |
|that cannot be lifted |that cannot be lifted |
| ISL stage I- accumulation of tissue fluid that subsides with limb elevation. | ISL stage I - accumulation of tissue fluid that subsides with limb elevation. |
|The oedema may be pitting at this stage |The oedema may be pitting at this stage |
| ISL stage II - Limb elevation alone rarely reduces swelling and pitting is | ISL stage II - Limb elevation alone rarely reduces swelling and pitting is |
|manifest |manifest |
| ISL late stage II - There may or may not be pitting as tissue fibrosis is more | ISL late stage II - There may or may not be pitting as tissue fibrosis is more |
|evident |evident |
| ISL stage III - The tissue is hard (fibrotic) and pitting is absent. Skin | ISL stage III - The tissue is hard (fibrotic) and pitting is absent. Skin |
|changes such as thickening, hyperpigmentation, increased skin folds, fat deposits|changes such as thickening, hyperpigmentation, increased skin folds, fat deposits|
|and warty overgrowths develop |and warty overgrowths develop |
|i. LIPEDEMA ASSESSMENT *NB- individuals can have symptoms of both lymphedema & lipedema |
|Right Leg |Left Leg |
|Lipedema S&S |Lipedema S&S |
|“diet resistant” fat deposits in legs bilaterally with symmetry, with no edema of|“diet resistant” fat deposits in legs bilaterally with symmetry, with no edema of|
|feet |feet |
| sharp demarcation between normal and abnormal tissue at the ankle giving | sharp demarcation between normal and abnormal tissue at the ankle giving |
|“pantaloon” appearance |“pantaloon” appearance |
| fatty pads anterior to lateral malleolus & between achilles tendon and medial | fatty pads anterior to lateral malleolus & between achilles tendon and medial |
|malleolus |malleolus |
| skin normal in texture without thickening or fibrosis seen in lymphedema (leg is| skin normal in texture without thickening or fibrosis seen in lymphedema (leg is|
|soft, not hard) |soft, not hard) |
|ACTIONS: Refer to a WCS/ ET Nurse for assessment for compression bandaging. |
|Refer to PT for ankle/calf-muscle pump training. |
|j. SKIN & ANATOMY |
|Right Leg |Left Leg |
|Venous Signs & Symptoms |Arterial Signs & Symptoms |Venous Signs & Symptoms |Arterial Signs & Symptoms |
|Varicosities |Hairless |Varicosities |Hairless |
|Hemosiderin staining |Thin |Hemosiderin staining |Thin |
|Chronic Lipodermatosclerosis |Shiny |Chronic Lipodermatosclerosis |Shiny |
|Acute lipodermatosclerosis |Dependent rubor |Acute lipodermatosclerosis |Dependent rubor |
|Stasis dermatitis |Blanching on elevation |Stasis dermatitis |Blanching on elevation |
|Atrophie blanche |Feet cool/cold/blue |Atrophie blanche |Feet cool/cold/blue |
|Woody fibrosis |Toes cool/cold/blue |Woody fibrosis |Toes cool/cold/blue |
|Ankle (submalleolar) flare |Lower temperature in right leg compared |Ankle (submalleolar) flare |Lower temperature in left leg compared |
|Ulcer base moist with granulation &/or |to left |Ulcer base moist with granulation &/or |to right |
|yellow slough/ fibrin |Capillary refill time: > 3 seconds |yellow slough/ fibrin |Capillary refill time: > 3 seconds |
|Ulcer located in gaiter region (lower |Ulcer located on foot or toes |Ulcer located in gaiter region (lower |Ulcer located on foot or toes |
|1/3 of calf) |Ulcer base pale and dry&/or contains |1/3 of calf) |Ulcer base pale and dry&/or contains |
|Ulcer located superior to the medial |eschar |Ulcer located superior to the medial |eschar |
|malleolus |Ulcer round and punched out in |malleolus |Ulcer round and punched out in |
|Scarring from prev. ulc. |appearance |Scarring from prev. ulc. |appearance |
| |Gangrene wet/dry | |Gangrene wet/dry |
|ACTIONS: To determine “healability” in order to recommend moist wound healing, or to determine the safety of applying compression bandages in all clients with |
|ulcers below the knee who exhibit ANY signs and symptoms of arterial disease, or when ANY compression bandaging is to be implemented, refer to a WCS/ ET Nurse or |
|diagnostic imaging for ABPI assessment. |
|k. UNUSUAL ULCER To be completed by WCS/ ET |
| Unusual location- ______________________________________________________ |
| Unusual appearance____________________________________________________ |
| Present longer than 6 months with failure to respond to optimal treatment |
|ACTIONS: Request tissue biopsy for wounds that suggest malignant growth or are non-responsive. For ulcers suggestive of pyoderma gangrenosum or cutaneous |
|vasculitits, request referral to wound care specialist physician or dermatologist for biopsy and treatment. If etiology is uncertain, refer to wound care |
|specialist physician. |
|l. CIRCULATION: PULSE ASSESSMENT |
|Right Leg |Left Leg |
|Dorsalis-Pedis: |Post-Tibial: |Dorsalis-Pedis: |Post-Tibial: |
|Present |Present |Present |Present |
|Diminished |Diminished |Diminished |Diminished |
|Absent |Absent |Absent |Absent |
|Comments: |Comments: |
| | |
|m. CIRCULATION: ABPI* |
|To be completed by WCS/ ET or in Vascular Lab–this may be done within 6 months prior to admission by a qualified health professional. |
|Right Leg |Left Leg |
|Dorsalis Pedis: |Post-tibial: |Dorsalis Pedis: |Post-tibial: |
|Digital: | |Digital: | |
|Brachial: |ABPI: |Brachial: |ABPI: |
|n. CIRCULATION: TOE PRESSURE or TOE BRACHIAL PRESSURE INDEX (TBPI) done in Vascular Lab |
|Right Foot |Left Foot |
|Toe Pressure*: |Toe Pressure*: |
|Brachial: |Brachial: |
|TBPI: |TBPI: |
|o. INTERPRETATION OF ABPI &/OR TOE PRESSURES AND LOWER LEG ASSESSMENT FINDINGS (See section F.6.6 re: compression) |
|ACTIONS (when assessed by a health professional with an appropriate scope of practice - MD or APN/ETN/WCS): |
|The measurements must always be interpreted within the context of the physical examination, assessment and client history. |
|Acceptable ABPI 0.8 to 0.9 → implement high compression therapy if indicated |
|Normal = 1.0 to 1.2. → implement high compression therapy if indicated |
|ABPI 0.8 - 1.2 in the presence of signs and symptoms of peripheral arterial disease, rheumatoid arthritis, diabetes mellitus or systemic vasculitis, further tests|
|should be considered prior to initiating (high) compression |
|Abnormal ABPI >1.2 (or unable to compress arteries )→ referral for further medical assessment e.g. segmental compression studies &/or Toe Brachial Pressure Index.|
|High reading could be due to abnormal vessel hardening from PVD, vessel calcification, edema, woody fibrosis, advanced age and long-standing hypertension. |
|Abnormal ABPI 0.5 to 0.8 warrants referral for further medical assessment e.g. segmental compression studies &/or Toe Brachial Pressure Index. May be mixed |
|venous/arterial ulcers → implement reduced compression bandaging |
|Abnormal ABPI ................
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