General
Medical History:
- Assess comorbidities, medications, allergies, and family history
Physical exam:
- Assess cardiovascular status (pulse, blood pressure)
- Perform focused examination of the legs
|
Expert Opinion |
D |
Venous Insufficiency |
Historical findings suggestive of venous insufficiency include:
- Prior history of thrombophlebitis, venous thromboembolism, and/or deep vein thrombosis
- History of symptomatic varicosities during pregnancy
- Surgical history of lower extremity trauma, vascular injury or previous varicose vein surgery
- Hypercoagulable states (e.g., cancer, infection, Factor VIII excess)
|
(Baker et al., 1991; Berard et al., 2002; Blomgren et al., 2001; Labropoulos et al., "Patterns," 2007; Fink et al., 2002; Dajani et al., 1988) |
B |
Physical findings suggestive of venous insufficiency include:
- Edema
- Wound presentation as shallow ulcer in the lower third of leg
- Venous dermatitis
- Lipodermatosclerosis
- Varicose veins
|
(Blomgren et al., 2001; Labropoulos et al., "Patterns," 2007; Wong, Duncan, & Nichols, 2003) |
B |
Diagnostic Tests:
- Doppler ultrasonography
- Duplex scanner plethysmography and venography
|
(Shami et al., 1993; Alguire & Mathes,1997; Wong, Duncan, & Nichols, 2003; Baxter & Polak, 1993) |
B |
Determine severity of venous insufficiency |
Expert Opinion |
D |
Arterial Occlusive Disease |
Assess for a history of arterial occlusive disease:
- Arterial peripheral vascular disease
- Ischemic complaints
- Rest pain
|
(Wipke-Tevis et al., 2000; Dormandy & Murray, 1991; Jelnes et al., 1986; Criqui et al., 1985; Marston et al., 2006; Hiatt, Hoag, & Hamman, 1995; Khan et al., 2006; Wang et al., 2005; Henke et al., 2005) |
B |
Assess for factors suggestive of arterial compromise:
- Cold, pale feet (in warm environment)
- Shiny, taut skin
- Dependent rubor
- Punched out appearance of ulcer
|
(Khan et al., 2006) |
B |
Diagnostic Tests:
- Ankle brachial index (ABI)
- If <0.8, referral to specialist may be necessary to assess for arterial occlusive disease
|
(Baxter & Polak, 1993; Dormandy & Murray, 1991; Jelnes et al., 1986; Stoffers et al., 1997; Marston et al., 2006; Hiatt, Hoag, & Hamman, 1995; Khan et al., 2006; de Vries et al., 2006; Ouwendijk et al., 2005) |
B |
Determine severity of arterial occlusive disease:
- ABI 0.6 to 0.8, suggestive of peripheral arterial occlusive disease
- ABI <0.5, suggestive of critical ischemia
- ABI >1.2, suggestive of calcification and noncompressibility of arterial wall
- Consider vascular intervention or reconstruction
- Contrast arteriography (or magnetic resonance angiography)
- Refer to vascular specialist, if needed
|
(Marston et al., 2006; O'Meara et al., 2000) |
B |
Diabetes
- Assess for comorbidities (microangiopathy, neuropathy, impaired immune response)
- Assess for sensory derangement (e.g., Semmes-Weinstein)
|
(Marston et al., 2006; Hiatt et al., 1995; Pham et al., 2000; Abbott et al., 1998; Yasuhara et al., 2002) |
B |
History and Characteristics of the Wound |
Document history of the wound:
- Date and site(s) current ulceration began
- Date and site(s) of previous ulcers
- Prior duration to heal
- Length of prior disease-free interval(s)
- Prior treatments
- Past surgical history of venous operation
- Use of compression garments
|
Expert Opinion |
D |
Document characteristics of the wound:
- Size
- Nature of wound base tissue
- Amount of drainage
|
(Marston et al., 2006; O'Meara et al., 2000) |
B |
Evaluate wound for evidence of infection
- Necrotic tissue
- Purulent drainage
- Odor
- Induration
- Cellulitis
|
(Cutting, 1998; Gardner et al., 2001) |
B |
For atypical and/or recalcitrant wounds, rule out other, less common causes of ulceration (biopsy may be necessary)
- Rheumatoid arthritis
- Sickle cell disease
- Pyogenic gangrenosum
- Tumors (squamous cell and basal cell carcinomas)
|
(Labropoulos et al., "Uncommon leg ulcers," 2007) |
B |
Additional Considerations: |
Assess for confounding factors:
- Impaired tissue perfusion (heart disease, obesity)
- Tissue hypoxia
- Metabolic disturbances (diabetes, nephropathy)
- Impaired healing
- Immunosuppression
- Tobacco use
- Infection (systemic and local)
- Nutrition and overall state of health
|
(Wipke-Tevis et al., 2000; Jelnes et al., 1986; Khan et al., 2006; O'Meara et al., 2000) |
B |
Assess and document allergies |
(Saap et al., 2004; Lim et al., 2007; Tavadia et al., 2003; Machet et al., 2004) |
B |
Assess for the presence of osteomyelitis:
- Bone exposed (or easily probed)
- Tissue necrosis overlying bone
- Gangrene
- Persistent sinus tract
- Underlying open fracture
- Underlying internal fixation
- Wound recurrence
Osteomyelitis evaluation:
- Radiographic studies (plain radiographs, nuclear bone scan and/or magnetic resonance imaging)
- If radiographic findings suggestive osteomyelitis, consider histologic evaluation and bone biopsy culture
|
(Shih, Shih, & Wong, 2005; Senneville et al., 2006) |
B |
Determine the presence of remote site or systemic infection (septicemia, endocarditis, prosthesis infection):
Anatomic risk factors include:
- Prosthetic heart valve
- Acquired cardiac valvular dysfunction
- Cardiac malformation
- Hypertrophic cardiomyopathy
- Orthopedic prosthesis
- Central nervous system (CNS) shunts
- Nearby arteriovenous fistula
|
(El-Ahdab et al., 2005)
| B |
Comorbid risk factors:
- History of bacterial endocarditis
- Immune compromised or suppressed host
- Colonization, multi-drug resistant organisms
|
(El-Ahdab et al., 2005) |
B |
Pain, Functional Status, and Quality of Life
- Assess pain level (Visual Analog Scale)
- Validated questionnaires can assess functional status and quality of life
|
Expert Opinion |
D |