The Red Recommendations at the End of Each Section Are ACTION Indicators

South West Regional
Wound Care Toolkit:
Interdisciplinary Lower Leg Assessment Form
Instructions for use:Competent/ Proficient/ Expert level HCP to complete if lower leg ulcer present or risk of ulcer is suspected. / Client Name:
Address:
Assessment Date:
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: / History of previous ulcer? Years:
Date of onset of current ulcer: / Date of onset of current ulcer:
Multiple wounds. / Multiple wounds.
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 / Arterial Symptoms / Other Symptoms / Venous Symptoms / Arterial Symptoms
deep bone pain
( Poss. osteomyelitis) / pain with deep palpation / knife-like / deep bone pain
( Poss. osteomyelitis) / pain with deep palpation / knife-like
pain in ulcer (Poss. Infection) / relieved with elevation / intermittent claudication / pain in ulcer (Poss. Infection) / relieved with elevation / intermittent claudication
known arthritis pain / Ache / increased pain with elevation / known arthritis pain / ache / increased pain with elevation
pain at night / pain at night
Comments: / Comments:
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 / dropped MTH / hammer toes / claw toes / dropped MTH
hallux valgus / dropped arch / calluses/corns / hallux valgus / dropped arch / calluses/corns
fixed ankle joint hallux rigidus fissures
other: / fixed ankle joint hallux rigidus fissures
other:
Nails:
thick / yellow / brittle / fungus / abnormal / thick / yellow / brittle / fungus / abnormal
ingrown: / ingrown:
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

Sensory: / burning
numbness / tingling / crawling / Sensory: / burning
numbness / tingling / crawling
Autonomic: / dry / cracking / fissures / Autonomic: / dry / cracking / fissures
Motor: / soft tissue distribution altered / Motor: / soft tissue distribution altered
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
Normal- no neuropathy / 1 Loss of protective sensation / 2aLoss of protective sensation and deformity / 2b
Peripheral arterial disease / 0
Normal- no neuropathy / 1 Loss of protective sensation / 2aLoss of protective sensation and deformity / 2b
Peripheral arterial disease
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 completely epithelialized / Superficial ulcer, not involving tendon capsule or bone / Ulcer penetrating to tendon or capsule / Ulcer penetrating to
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 / foot / B/K / Location: / toes / foot / B/K
A/K / sacral / ascites / A/K / sacral / ascites
Description: Press finger into edema x 10 –15 seconds. / Description: Press finger into edema x 10 –15 seconds.
Pitting: / 1+ = 0 - ¼” / 2+ = ¼” – ½” / 3+ = ½ - 1” / Pitting: / 1+ = 0 - ¼” / 2+ = ¼” – ½” / 3+ = ½ - 1”
4+ = takes several minutes to rebound / 4+ = takes several minutes to rebound
non-pitting / brawny induration / non-pitting / brawny induration
Measurements: / Measurements:
Midfoot= / cm / Heel→10cm= / cm / Midfoot= / cm / Heel→10 cm= / cm
Heel→20 cm= / cm / Heel→30 cm= / cm / Heel→20 cm= / cm / Heel→30 cm= / cm
Heel→ cm= / cm / Heel→ cm= / cm / Heel→ cm= / cm / Heel→ cm= / cm
Heel→ cm= / cm / Heel→ cm= / cm / Heel→ cm= / cm / Heel→ cm= / cm
Previous compression stockings / Previous compression stockings
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 that cannot be lifted / Positive Stemmer’s sign - A thickened skin fold at the base of the second toe that cannot be lifted
ISL stage I- accumulation of tissue fluid that subsides with limb elevation. The oedema may be pitting at this stage / ISL stage I - accumulation of tissue fluid that subsides with limb elevation. The oedema may be pitting at this stage
ISL stage II - Limb elevation alone rarely reduces swelling and pitting is manifest / ISL stage II - Limb elevation alone rarely reduces swelling and pitting is manifest
ISL late stage II- There may or may not be pitting as tissue fibrosis is more evident / ISL late stageII- There may or may not be pitting as tissue fibrosis is more evident
ISL stage III - The tissue is hard (fibrotic) and pitting is absent. Skin changes such as thickening,hyperpigmentation, increased skin folds, fat deposits and warty overgrowths develop / ISL stage III - The tissue is hard (fibrotic) and pitting is absent. Skin changes such as thickening,hyperpigmentation, increased skin folds, fat deposits and warty overgrowths develop
i. LIPEDEMA ASSESSMENT *NB- individuals can have symptoms of both lymphedema & lipedema
Right Leg / Left Leg
Lipedema S&S
“diet resistant” fat deposits in legs bilaterally with symmetry, with no edema of feet / Lipedema S&S
“diet resistant” fat deposits in legs bilaterally with symmetry, with no edema of feet
sharp demarcation between normal and abnormal tissue at the ankle giving “pantaloon” appearance / sharp demarcation between normal and abnormal tissue at the ankle giving “pantaloon” appearance
fatty pads anterior to lateral malleolus & between achilles tendon and medial malleolus / fatty pads anterior to lateral malleolus & between achilles tendon and medial malleolus
skin normal in texture without thickening or fibrosis seen in lymphedema (leg is soft, not hard) / skin normal in texture without thickening or fibrosis seen in lymphedema (leg is 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
Hemosiderin staining
Chronic Lipodermatosclerosis
Acute lipodermatosclerosis
Stasis dermatitis
Atrophie blanche
Woody fibrosis
Ankle (submalleolar) flare
Ulcer base moist with granulation &/or yellow slough/ fibrin
Ulcer located in gaiter region (lower 1/3 of calf)
Ulcer located superior to the medial malleolus
Scarring from prev. ulc. / Hairless
Thin
Shiny
Dependent rubor
Blanching on elevation
Feet cool/cold/blue
Toes cool/cold/blue
Lower temperature in right leg compared to left
Capillary refill time: > 3 seconds
Ulcer located on foot or toes
Ulcer base pale and dry&/or contains eschar
Ulcer round and punched out in appearance
Gangrene wet/dry / Varicosities
Hemosiderin staining
Chronic Lipodermatosclerosis
Acute lipodermatosclerosis
Stasis dermatitis
Atrophie blanche
Woody fibrosis
Ankle (submalleolar) flare
Ulcer base moist with granulation &/or yellow slough/ fibrin
Ulcer located in gaiter region (lower 1/3 of calf)
Ulcer located superior to the medial malleolus
Scarring from prev. ulc. / Hairless
Thin
Shiny
Dependent rubor
Blanching on elevation
Feet cool/cold/blue
Toes cool/cold/blue
Lower temperature in left leg compared to right
Capillary refill time: > 3 seconds
Ulcer located on foot or toes
Ulcer base pale and dry&/or contains eschar
Ulcer round and punched out in appearance
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:
Present
Diminished
Absent / Post-Tibial:
Present
Diminished
Absent / Dorsalis-Pedis:
Present
Diminished
Absent / Post-Tibial:
Present
Diminished
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- 1.2in the presence ofsigns 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 assessmente.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 <0.5severe peripheral arterial disease→ urgent vascular surgery consult.NO compression to be used.
Acceptable TBPI N=0.5 to 0.75, TP (toe pressure) = 70 to 110 mmHg→ implement high compression therapy if indicated
Abnormal TBPI < 0.2 or TP < 30 mmHg → urgent vascular surgery consult.NO compression to be used.

p.

Summary of findings: ______

______

______

Type of wound:

Wound Type
 Surgical  Open  Closed
 Trauma  Superficial/ Partial Thickness Burn
 Full-thickness burn d/c from hospital
 Skin Tear /Abrasion  Malignant
 Inflammatory
 Unknown
Other: / Ulcer Type
 Venous Leg Ulcer  Arterial Leg Ulcer
 Mixed Leg Ulcer  Diabetic foot Ulcer
 Pressure Ulcer
 Suspected Deep Tissue Injury
 Stage I
 Stage II
 Stage III
 Stage IV
 Unstageable

Impression re: Healability: Please see section E.1“Determine Healability of Wound Tool”

Need for Interdisciplinary Interventions:(see section E.6 for criteria)______

______

______

______

______

Signature and status:______Date: ______

1

SWRWCToolkit_B.2.2_Interdis. Lower Leg Assess. Tool_Jan 16 2011 Appropriate credit or citation must appear on all copied materials.