leg ulcer assessment chart

Yes
Arterial ankle brachial pressure index < 0.8

Yes
Arterial ankle brachial pressure index > 0.8

Yes
Venous

Refer to Vascular Unit

Use appropriate dressing according to clinical indications.
No compression.
Analgesia

Follow Trust Treatment
protocol for venous leg ulcers
Reassess every 3 months

Refer to specialist

Protocol for Assessment of Patient Admitted with Leg Ulcer

Obtain history of: Current Medication Allergies Duration of present ulcer Onset of 1st ulcer Number of episodes		Obtain history of contributing factors Tobacco usage Limited Mobility Under nourishment Obesity Social Isolation History of non-compliance		Obtain history of predisposing factors Previous DVT Phlebitis Cellulitis Fracture Vascular Surgery Orthopaedic Surgery Trauma Pregnancies MI - Angina CVA - TIA Rheumatoid Arthritis Diabetes Hypertension

Examine the limb for clinical signs and symptoms Varicose Veins , Skin pigmentation , Induration , Ankle flare , Generalised Oedema, Atrophy blanche Strong / weak / absent pedal pulses, intermittent claudication , Ischaemic rest pain, Pain relief when leg lowered , Foot dusky pink when elevated, Shiny hairless skin

Examine surrounding skin Normal Dry eczema Wet eczema Maceration Cellulitis		Record the ulcer aspect and appearance Using Leg Ulcer Assessment Form Anterior , Medial, Lateral, Posterior, Circumferential Length of ulcer in cms, Width of ulcer in cms Circumference of ankle in cms, Circumference of calf in cms Slough , Necrosis Sloping edges, Rolled edges Granulation , "Cliff" punched out

Measure ankle / brachial pressure

Trace of photograph wound and put into care plan

Record finding of the holistic assessment on the Leg Ulcer Assessment Form	Yes	Has the patient had the following investigations ? Blood pressure FBC and ESR Urine analysis Wound swab, if clinically indicated	No	Arrange investigations

Photocopy form and file in patient's notes		Discuss assessment findings with MDT		Has the ulcer type been identified ?