VOL: 98, ISSUE: 44, PAGE NO: 60
Judy Harker, RGN, DN, BNurs, Post Grad Dip, is nurse consultant, tissue viability, Royal Oldham Hospital
Assessing a patient with leg ulceration is the first step in their journey towards potential healing. It is necessary to determine the correct aetiology of the ulcer and exclude those patients with arterial disease for whom compression is dangerous (Stacey et al, 2002). When managing a patient, a visual assessment alone is considered unsatisfactory (Elliott et al, 1996). Instead, skilled assessment and ulcer diagnosis is advocated and well supported by national guidelines (Clinical Resource Efficiency Support Team, 1998; RCN, 1998; Scottish Intercollegiate Guidelines Network, 1998). It is also the responsibility of the health care professional to be trained in leg ulcer management (RCN, 1998). The assessment process can be divided into three stages: assessment of the patient, the limb and finally the ulcer itself.
Assessment of the patient as a whole
Begin with the age, gender and occupation of the patient. These are significant because the incidence of leg ulceration increases with age and women may develop a deep vein thrombosis or varicose veins as a result of pregnancy. Occupations that require people to stand for long periods may also contribute to ulcer pathology (Morison and Moffatt, 1994). - Baseline measurements of blood pressure, urinalysis and weight should be taken routinely (RCN, 1998);
- Past medical history - record the previous medical and surgical history as the management of the ulcer will often be influenced by the patient’s co-morbidity (Table 1);
- Allergies - record allergies to medication/dressings. Contact dermatitis is a common problem associated with leg ulcers (Cameron, 1995);
- Mobility - observing the degree of mobility is required since, for example, immobility, limited or fixed ankle joint, will affect the effectiveness of the calf muscle pump (Cullum and Roe, 1995);
- Smoking history - smoking is a risk factor for arterial disease and it is also known to delay wound healing (Siana et al, 1992).
- Social support - it is good practice to establish what social support patients have at home. If they are socially isolated and depressed this may significantly influence the length of time the ulcer takes to heal (Lindsay, 2001). Ascertain the patient’s understanding of the ulcer and how it was caused, how it is affecting their life and their involvement in the treatment programme;
- Pain - assessment of pain is sometimes inadequate in leg ulcer management (Roe et al, 1993). However, careful assessment can prove to be a useful determining factor of ulcer pathology.
Symptoms suggestive of arterial disease may include night pain - relieved by hanging the leg downwards out of bed - pain in the calf, thigh or buttock on walking and relieved at rest, pain when the affected limb is elevated, pain in the limb/foot when the limb is dependent (rest pain), and pain so severe at night that the patient has to sleep in chair.
Symptoms suggestive of venous disease may include pain when the limb is dependent but improves on elevation, and night cramps which improve on walking.
Determine from the patient the exact location of the pain, its frequency, strategies used to alleviate it and details of any analgesia used.
- Nutrition - both over- and under-nourishment will influence ulcer healing and provide clues about ulcer pathology. Obesity can result in reduced mobility and impaired venous return, while malnourishment can starve ulcer tissue of vital nutrients required for wound healing (Armstrong, 1998).
- Medication - the patient’s current medication should be noted, including drugs that are known to delay healing - for example, steroids and cytotoxic drugs.
Wherever possible, encourage carers or relatives to be present at the time of the assessment. The patient may provide a poor history, fail to elicit crucial clinical information or be in denial of the symptoms associated with the ulcer, thereby inadvertently misleading the assessor.
Assessment of the leg
All patients should be given the benefit of Doppler ultrasound measurement of ankle brachial pressure index (ABPI), as this is regarded as the most reliable way of detecting arterial insufficiency (Moffatt and O’Hare, 1995). Patients with an ABPI < 0.8 should be assumed to have arterial disease (SIGN, 1998). Patients with diabetes should be assessed by waveform analysis and toe pressure measurement in an attempt to gain more reliable results (Stacey et al, 2002).
Both limbs should be carefully inspected for clinical signs suggestive of venous and arterial disease (Tables 2 and 3).
Ask the patient about any previous episodes of ulceration. Ascertain what therapies were used in the past (both successful and unsuccessful), how long the ulcers took to heal and the time free from ulceration. Look for oedema within the limb, the severity and distribution. Its cause should be determined to aid assessment. Document the ankle and calf circumference as baseline information.
Ensure the patient is standing or has the limb in the dependent position so that any varicosities can become more visible and are easier to locate. Always inspect the patient’s footwear: ill-fitting shoes or slippers may interfere with ulcer healing.
Assessment of the ulcer
Assessment should include the following:
- Ulcer size - surface measurement of the ulcer is a reliable index of healing and should be carried out over time. It is suggested that larger ulcers (>25cm2) take longer to heal than smaller ulcers (Vowden et al, 1997).
- Depth/ulcer base - always describe the depth or the base of the ulcer. Ulcers that reveal tendon, fascia or bone may have an arterial component to them. Describe the ulcer base in terms of the type of tissue present and the quantity expressed as a percentage - bone, fascia, tendon, necrotic tissue, slough, granulation tissue, over-granulation tissue, epithelial tissue. A description of the ulcer base will aid dressing choice and determine the progress of the wound;
- Exudate - record the quantity and colour of wound exudate, which will help identify the presence of clinical infection. Wound swabbing for bacteriological analysis should only be carried out where there is evidence of clinical infection - for example, ulcer deterioration, cellulitis, pyrexia, increasing exudate, increasing pain or odour (Cutting and Harding, 1994).
- Location (and location of previous ulcers) - the location of the ulcer is often thought to be indicative of the underlying cause. Document the location of the ulcer/s clearly.
- Appearance of the edge of the ulcer and presence of signs of infection - the ulcer edge often gives a good indication of progress towards healing and should be carefully documented. Epithelialising edges usually suggest that healing is taking place. The appearance of a rolled edge may be indicative of malignancy. A non-healing or atypical ulcer should be referred for biopsy (Taylor et al, 1997). Note the condition of the surrounding skin, recording the presence of associated skin problems.
Question the patient about the circumstances surrounding the initial development of the ulcer, as it can assist ulcer diagnosis.
Suggested referral criteria
Managing a patient with a leg ulcer remains the responsibility of the multiprofessional team, and one of the most fundamental aspects of effective care is knowing when to refer a patient and to whom (Table 4).
Ensure that assessment findings are carefully recorded and relevant health care professionals are informed of diagnosis and treatment plan.
Conducting a thorough examination before a treatment regime is started is well worthwhile. This reduces the risk of harmful interventions and maximises overall benefit to the patient.