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Identify and Treat the Cause: 4.3 Complete a Holistic Assessment


Level C: RNAO's Interpretation of Evidence:1

  • Information obtained should be documented in a structured format assessment form
  • Should be undertaken by healthcare professional(s) trained and experienced in surgical wound management

a. Obtain a comprehensive patient history including:

  • Medical history
  • Family medical history
  • History of deep vein thrombosis (DVT) and/or lower leg injury
  • History of episodes of chest pain, hemoptysis or pulmonary embolus
  • History of heart disease, stroke or transient ischemic attack (TIA)
  • Comorbidities
  • Pain
  • Where patient sleeps at night
  • History
  • Surgical procedure and wound care history
  • Current and past medications (Prescription, non-prescription, naturopathic, vitamin/mineral supplementation and illicit drug use including e-cigarettes, inhaled substances and nicotine replacement therapy)
  • Nutritional status
  • Allergies
  • Psychosocial status including quality of life
  • Functional, cognitive, emotional status and ability for self-care
  • Lifestyle (activity level, interests, employment, dependents, support system)
Transfer of care communications received and reviewed
  • Wound history
  • Wound measurements and percentage of healing (initial and current measurements)
  • Dressing and treatment history
  • Medication use
  • Diagnostic/vascular/lab results
  • Discharge summary
  • Consultation notes
  • Care plan
  • Details of surgery and complications
  • Nursing notes re: dressing changes etc.
Diabetes

Home glycemic control and monitoring if patient is diabetic
  • Blood sugar (BS) and A1C are within recommended range
  • Use of glucose log book (Diabetes Passport/Diabetic Log Book)
  • Adequate insulin supplies
  • Glucometer and required supplies
  • Assess for barriers in monitoring glycemic control
  • Community/health resources
  • Diabetic Education Program

b. Complete a comprehensive physical examination including:

  • Blood Pressure, height, weight, BMI, pulses in foot and ankle
  • Review bloodwork that should include the following:
 
Protein-Calorie Malnutrition
  • Pre-albumin if available (low scores indicate risk for malnutrition)
  • Serum albumin level (<30g/l will delay healing; <20g/l will be non-healable)
  • C-reactive Protein (CRP)
Check for anemia
  • CBC (including RBC, Hct, Hgb, MCV, Platelets etc.)
   If anemic, proceed to checking -->
  • Serum Iron
  • Total Iron Binding
  • Ferritin
  • Transferrin
  • B12
  • Red blood cell folate level
Kidney function (To check hydration)
  • BUN
  • Creatinine
  • Potassium
 

c. If surgical wound is on lower leg (Complete a lower leg assessment):

Level A: RNAO's Interpretation of Evidence:2

Perform a BILATERAL lower leg assessment including ABPI/TBPI

“All clinicians involved in the management of patients with lower limb ulcers should have direct access to an 8 MHz hand held Doppler device. This should not be considered a special investigation limited to vascular laboratory”3

Assess for the following:

  • ABPI/TBPI or arterial vascular studies have been completed within last 3 mths and results documented
  • If unable to obtain ABPI/TBPI, referral to vascular surgeon is recommended
  • Assess pulses (popliteal – behind knee , dorsalis pedis – top of foot , posterior tibial – medial ankle)
  • Assess capillary refill (normal less than 3 seconds)
  • Leg measurements (foot, ankle, calf, thigh) to assess edema
  • Ankle range of motion (ROM)
  • Foot deformities
  • Ankle flare
  • Skin temperature (compare both legs)
  • Skin colour (dependent and on elevation)
  • Interdigital spaces
  • Drainage on socks
  • Presence of pain
  • Nail changes (thicker, dry, crumbly, presence of fungal infection)
  • Presence of hair on lower leg, feet and toes
  • Presence of varicosities (varicose veins)
  • Dermatological changes due to impaired blood flow
  • History of compression
  • Sudden onset of pain
  • Repeat ABPI/TBPI assessment every 3 months if healing is not progressing

Perform ABPI/TBPI to assess healability and to rule out arterial disease. If patient is a diabetic, toe pressures should be obtained.

An Ankle Brachial Pressure Index (ABPI) measurement should be performed by a trained practitioner to rule out the presence of peripheral arterial disease, particularly prior to the application of compression therapy. ABPI measurement offers valuable information as a screening tool for lower extremity peripheral arterial disease.4
 

Ankle Brachial Pressure Index (ABPI) / Toe Brachial Pressure Index (TBPI) Interpretations

ABPI

 > 0.9-1.2 ....Normal (1.2 or > could indicate calcification, seen in diabetes, patients that smoke, hypertension, rheumatoid arthritis, systemic vasculitis or advanced age). Referral is recommended for vascular arterial testing

0.80-0.9 ......Mild ischemia (inflow disease may be present)

0.50-0.79 ....Moderate ischemia (Would benefit from vascular surgeon consult to expedite wound healing)

0.35-0.49 ....Moderately severe ischemia (Urgent vascular surgery consult recommended)

0.20-0.34 ....Severe ischemia (Urgent vascular surgery consult recommended)

<0.20 ..........Likely critical ischemia, but absolute pressure and clinical picture must be considered


TBPI:

> 0.7 …………Normal > 0.7 (When TBPI is high, a referral for vascular arterial testing is recommended)

 0.64 - 0.7…..Borderline

< 0.64………. Abnormal indicating arterial disease  (Urgent vascular surgery consult recommended)

Lower Leg Vascular Assessment

RNAO recommends a 3 month complete reassessment if no evidence of healing and a 6 month reassessment for resolving and healing (but not yet healed) wounds

If ulceration does not heal or show improvement after 3 months and patient has an Ankle Brachial Pressure Index (ABPI) of > 0.8 to 1.3, a referral to a vascular surgeon to review potential surgical interventions is recommended

Right

 

Left

ABPI: TBPI: ABPI: TBPI:
     

Further Investigation Required

 RNAO Interpretation of Evidence5



An Ankle Brachial Pressure Index (ABPI) >1.2 and <0.8 warrants referral for further medical assessment. People with abnormally low or abnormally high ABPI should be further investigated for peripheral arterial disease. For example, an ABPI >1.3 is considered indicative of non- compressible vessels that are found in individuals with diabetes, chronic renal failure and who are older than 70 years of age. In these cases, compression therapy may not be recommended.6
 
ABPI 0.5 to 0.8 TBPI 0.64 to 0.7
Suggest Transcutaneous Oxygen Pressure (TcPO2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies
 
ABPI <0.5 TBPI <0.64
Urgent vascular surgical consult needed


Referrals to vascular lab may be required for the following investigations:

Transcutaneous oxygen (TCP02)
  • Measures partial pressure in adjacent areas of the wound
  • Considered reliable method to measure the viability of tissue except where acute edema or inflammation is present
  • Tissue hypoxia results TCP02 <40 mmHg
  • Critical ischemia TCP02 <30 mmHg
Laser Doppler Flow
  • Useful in cases where false readings obtained in TCP02 (where acute edema or inflammation is present)
Doppler Arterial Waveforms
  • Non-invasive
  • Demonstrates the normal tri-phasic signal of the pulse
Segmental Doppler Pressures
  • Determines location of vascular lesion
  • Pressures measured at thigh, above knee, calf and ankles
  • Results compared with each other and with other leg
Imaging Studies (Angiography)
  • Determines location and extent of disease
  • Used by surgeon to provide roadmap in deciding and planning revascularization of the limb

 

Identify and Treat the Cause: 4.4 Assess the Wound and Peri-Wound

 
  1. Ontario, Registered Nurses Association of. Assessment and Management of Venous Leg Ulcers. Toronto : s.n., 2004.
  2. Ontario, Registered Nurses Association of. Assessment and Management of Venous Leg Ulcers. Toronto : s.n., 2004.
  3. Arterial Disease Ulcers Part 1: Clinical Diagnosis and Investigation. Weir GR, Smart H, Marle JV, Cronje FJ. September, s.l. : Advances in Skin and Wound Care, 2014.
  4. Arterial Disease Ulcers Part 1: Clinical Diagnosis and Investigation. Weir GR, Smart H, Marle JV, Cronje FJ. September, s.l. : Advances in Skin and Wound Care, 2014.
  5. Ontario, Registered Nurses Association of. Assessment and Management of Venous Leg Ulcers. Toronto : s.n., 2004.
  6. Ontario, Registered Nurses Association of. Assessment and Management of Venous Leg Ulcers. Toronto : s.n., 2004.

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