Address: Left Leg. other: Nails: thick yellow brittle fungus abnormal thick yellow brittle fungus abnormal

Transcription

1 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 Client Name: Address: suspected. The red recommendations at the end of each section are ACTION indicators. a. ULCER OR PRE-ULCEROUS CONDITIONS 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. History of previous ulcer? Years: Date of onset of current ulcer: Multiple wounds. Locations: Skin stretched with imminent breakdown. Serous weeping from leg without signs of ulceration. Sub-keratotic hemorrhage under callus. Probes to bone History of previous ulcer? Years: Date of onset of current ulcer: Multiple wounds. Locations: Skin stretched with imminent breakdown. Serous weeping from leg without signs of ulceration. Sub-keratotic hemorrhage under callus. Probes to bone 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) 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) known arthritis pain relieved with elevation Ache intermittent claudication increased pain with elevation pain at night pain in ulcer (Poss. Infection) known arthritis pain 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 relieved with elevation ache intermittent claudication increased pain with elevation pain at night 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 fixed ankle joint hallux rigidus fissures other: other: Nails: thick yellow brittle fungus abnormal thick yellow brittle fungus abnormal ingrown: ingrown: SWRWC Toolkit_B.2.2_Interdis. Lower Leg Assess. Tool_Jan Appropriate credit or citation must appear on all copied materials. 1

2 Footwear: orthotics not being worn at all times, indoor or out presence of pressure areas Location: inappropriate footwear d. TEST FOR NEUROPATHY Applicable Not Applicable Sensation Score: /10 Sensation Score: / point Monofilament Neuropathic Assessment - Indicate with a + or - the presence or absence of sensation Dorsum Right Foot (-) sensation absent (+) sensation present Dorsum Left Foot Plantar Foot Right Left Sensory: burning tingling Sensory: burning tingling crawling numbness crawling numbness Autonomic: dry cracking Autonomic: dry cracking fissures 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 0 1 Loss of 2a Loss of 2b 0 1 Loss of 2a Loss of 2b Normal- no protective protective Peripheral Normal- no protective protective Peripheral neuropathy sensation sensation and arterial neuropathy sensation sensation and arterial disease disease deformity deformity 3a Previous history of DFU 3b Previous history of amputation 3a Previous history of DFU 3b Previous history of amputation 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 SWRWC Toolkit_B.2.2_Interdis. Lower Leg Assess. Tool_Jan Appropriate credit or citation must appear on all copied materials. 2

3 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) Date of Date of onset: 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 seconds. Description: Press finger into edema x seconds. Pitting: 1+ = 0 - ¼ 2+ = ¼ ½ 3+ = ½ - 1 Pitting: 1+ = 0 - ¼ 2+ = ¼ ½ 3+ = ½ = 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 Positive Stemmer s sign - A thickened skin fold at the base Positive Stemmer s sign - A thickened skin fold at the base of the second toe that cannot be lifted of the second toe that cannot be lifted ISL stage I- accumulation of tissue fluid that subsides with ISL stage I - accumulation of tissue fluid that subsides with limb elevation. The oedema may be pitting at this stage limb elevation. The oedema may be pitting at this stage ISL stage II - Limb elevation alone rarely reduces swelling ISL stage II - Limb elevation alone rarely reduces swelling and pitting is manifest and pitting is manifest ISL late stage II - There may or may not be pitting as tissue ISL late stage II - There may or may not be pitting as tissue fibrosis is more evident fibrosis is more evident ISL stage III - The tissue is hard (fibrotic) and pitting is ISL stage III - The tissue is hard (fibrotic) and pitting is absent. Skin changes such as thickening, hyperpigmentation, absent. Skin changes such as thickening, hyperpigmentation, increased skin folds, fat deposits and warty overgrowths increased skin folds, fat deposits and warty overgrowths develop develop i. LIPEDEMA ASSESSMENT *NB- individuals can have symptoms of both lymphedema & lipedema 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 fatty pads anterior to lateral malleolus & between achilles tendon and medial malleolus 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 fatty pads anterior to lateral malleolus & between achilles tendon and medial malleolus SWRWC Toolkit_B.2.2_Interdis. Lower Leg Assess. Tool_Jan Appropriate credit or citation must appear on all copied materials. 3

4 skin normal in texture without thickening or fibrosis seen in skin normal in texture without thickening or fibrosis seen in lymphedema (leg is soft, not hard) 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 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 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 Dorsalis-Pedis: Post-Tibial: Also seen with Neuropathy Dorsalis-Pedis: Post-Tibial: Also seen with neuropathy 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. Dorsalis Pedis: Post-tibial: Dorsalis Pedis: Post-tibial: Digital: Digital: Brachial: ABPI: Brachial: ABPI: SWRWC Toolkit_B.2.2_Interdis. Lower Leg Assess. Tool_Jan Appropriate credit or citation must appear on all copied materials. 4

5 n. CIRCULATION: TOE PRESSURE or TOE BRACHIAL PRESSURE INDEX (TBPI) done in Vascular Lab 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 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 <0.5 severe 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 Ulcer Type Surgical Open Closed Venous Leg Ulcer Arterial Leg Ulcer Trauma Superficial/ Partial Thickness Burn Full-thickness burn d/c from hospital Skin Tear /Abrasion Malignant Inflammatory Unknown Other: Mixed Leg Ulcer Pressure Ulcer Suspected Deep Tissue Injury Stage I Stage II Stage III Stage IV Unstageable Diabetic foot Ulcer 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: SWRWC Toolkit_B.2.2_Interdis. Lower Leg Assess. Tool_Jan Appropriate credit or citation must appear on all copied materials. 5