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 |

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|[pic] |

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|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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