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262 ASSESSMENT OF LEG ULCERATION
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TABLE5.7 Descriptions ofexudates andtheir signicance.
Type Consistency Colour Signicance
Serous Thin, watery Clear,
straw-
coloured
Fibrinous Thin, watery Cloudy May indicate the
Sero-
sanguineous
Sanguineous Thin, watery Reddish Low protein content
Purulent Viscous,
Thin, slightly
thicker
than water
sticky
Clear, pink Presence of red
Opaque, milky,
yellow or
brown,
sometimes
green
Often considered
normal, but
increased volume
may indicate
infection (e.g.
Staphylococcus
aureus). May also
be due to uid
from urinary or
lymphatic stula.
presence of brin
strands, which
would indicate a
response to
inammation.
blood cells
indicates capillary
damage (e.g. after
surgery or a
traumatic
dressing removal).
due to venous or
congestive
cardiac disease,
malnutrition or
enteric or
urinary fistula.
White blood cells,
bacteria, slough or
from enteric or
urinary stula.
Bacterial infection
(e.g. Pseudomonas
aeruginosa).
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TABLE5.7
Type Consistency Colour Signicance
Haemopurulent Viscous Reddish, milky Established
Haemorrhagic Viscous Dark red Capillaries break
Source: Adapted from World Union of Wound Healing Societies (2007), Wounds UK
(2013) and Nichols (2016).
(Continued)
infection. May
contain
neutrophils, dying
bacteria,
inflammatory
cells, blood
leakage due to
dermal capillaries,
some bacteria.
down easily and
bleed due to
infection
or trauma.
SKIN ASSESSMENT
The skin surrounding wounds often has compromised integrity
caused by tissue inammation. Surrounding skin is more susceptible
to irritation, maceration and loss of epithelium as a result of moisture
damage and wound exudate (Dini etal. 2020). Observation of the
peri- wound via uorescent imagery (MolecuLight) indicates for most
wounds an elevated level of bacteria that can transfer into the wound
bed (Sharpe et al. 2022). Early recognition of the risk of skin
breakdown is an essential part of prevention. The skin should be
assessed holistically as part of the patient’s regular assessment and
reassessment (Table5.8):
Ask the patient about their normal skin well- being, including
skin hygiene, integrity and management (Mitchell2022).
Note any changes in the skin colour or discoloration (refer to
Table5.2).
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TABLE5.8
Dry, aky skin and varicose
eczema. Also known as
gravitational eczema or venous
stasis (Atkins etal.2020).
Hyperkeratosis– thick, scaly
skin– is caused by increased
production of keratin, a protein
in the skin, causing thickness in
the stratum corneum. The
extent to which this can build
up varies and increases the risk
of infection as the thick moist
scales are a breeding ground for
bacteria (Wounds UK2016).
Excoriation– red, inamed skin
caused by wound exudate or
lymphorrhoea.
Maceration– white, soggy skin
saturated by poor uid
management.
Skin assessment.
A good skincare regime is required
with washing and thorough drying
of skin. Using soap substitutes
alongside emollients can support
skin integrity (Wounds UK2020).
Varicose eczema may be treated with
a course of topical steroids (NHS
Inform2022).
Remove thick plaques by gently
debriding with a gloved hand,
forceps or debridement pad or
cloth (Wounds UK2016).
Consider wound dressing and apply
barrier lm to protect the
surrounding skin.
Increase the frequency of dressing
changes and consider the type of
super- absorbent dressing and its
placement. Dressings should be
placed distally to the leg ulcer to
prevent exudate from running
down the limb. Check and
encourage limb elevation to aid
venous return (Brown2017).
Evaluate the ecacy of compression
therapy and whether it is at a
therapeutic dose.
Note any changes in rmness or moisture.
Assess the peri- wound (Table5.6).
Assess the peri- wound for localised maceration caused by the
removal of skin dressings and dressing adherence that has
aected the skin barrier by stripping away parts of the epidermis
(Mitchell and Hill2020).
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DIAGNOSTIC ASSESSMENT
Ankle brachial pressure index (ABPI) testing is a non- invasive way to
assess an individual’s vascular status and identify the presence,
absence or degree of PAD. It forms a signicant part of the overall
holistic assessment (Wounds UK2019a). A Doppler ultrasound measures the amount of blood ow in a patient’s arteries in the lower limb
using high- frequency sound waves. Vascular ow studies detect
abnormal blood ow in the arteries and veins. The purpose of ABPI
testing is to assess the degree of arterial perfusion at the ankle (Wounds
UK2019a) and as such it does not diagnose the cause of the ulcer.
Modalities for assessing vascular status are as follows (Wounds
UK2019a):
Ankle brachial pressure index (ABPI)– an automated or hand-
held device is used to exclude the signicance of arterial disease
and record the arterial blood ow at the ankle compared with
pressure at the arm (brachial).
Toe brachial pressure index (TBPI)– an automated or handheld
device is used to record the arterial blood ow at the toe compared with blood ow at the arm (brachial). The cu is placed on
the hallux to obtain toe pressure. This method is often used in
practice if a cu cannot go around the ankle due to pain, ulceration, lymphoedema or obesity, or if it has not been possible to
occlude the vessels in the lower leg, so instead using the smaller
vessels in the toe, which tend to become damaged only in more
advanced disease, is recommended.
Pulse oximetry– a secondary investigation by using a pulse oxime-
ter to measure blood oxygen levels. The ow of oxygenated blood
can be assessed on a limb after the application of compression
therapy to see if it decreases as the compression therapy has been
applied. This may be useful to add conrmation that a limb is suitable for compression and is sometimes used within GP practices. It
is important to note that this method is not reliable at excluding PAD.
Modalities for assessing arterial disease (medical) include
thefollowing:
Arterial duplex scan– an ultrasound scan of the arteries, which
is usually rst line within vascular services. It can show the
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structure and formation of the vessels as well as detecting the
rate of blood ow.
Computer tomography angiogram (CTA)– used for looking at
the arterial system from the aorta and below. Using a contrast
radioactive highlights any narrowing in the arteries.
Magnetic resonance angiogram (MRA)– like CTA but uses lower
levels of radioactive dye with magnetic elds, which may be a
safer option for patients who also have renal disease.
The following should undergo ABPI testing (Wounds UK2019a):
Patients presenting with a lower limb wound irrespective of sus-
pected aetiology to assess for PAD.
Patients who are considered high risk, e.g. those with diabetes or
who are immobile.
Patients presenting with lower limb changes.
Patients with stigmata of disease but no ulceration, to halt the
progression and initiate early intervention.
Patients with any symptoms of PAD, to conrm or
exclude disease.
Patients with early or established lower limb swelling, as early
intervention can halt the progression and identify treatment choices.
Patients who are currently receiving treatment with compres-
sion therapy, as part of reassessment and before the issue of any
new garments. This is to ensure that their arterial status has
not altered.
All these patients at regular reassessment intervals of 3, 6 or
12 months. Frequency depends on ongoing assessment
outcomes, cardiovascular risk status, patient needs and
localguidelines.
Many people may not understand the vascular assessment process. It is important to inform the patient about how it works, why it
is being conducted and how the results will be interpreted, using
plain language and terms the person can easily understand. Some
people may nd the procedure dicult to tolerate, particularly if
they are unable to lie at due to pain or mobility issues, breathing
problems or weight issues. The misconception that ABPI testing in
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the incorrect position is ‘better than not doing it’ should be challenged, as it can cause incorrect readings and discrepancies in results
and is therefore not advocated (Wounds UK2019a).
Factors that may aect the patient’s ability to undergo ABPI test-
ing in the usual way include (Staines2018; Wounds UK2019a):
Unmanaged pain.
Surgery to arm or leg.
Lymph node clearance.
Cancer- related treatment.
Circumferential ulceration (consider TBPI).
Cellulitis (not a contraindication, but dependent on level of pain
as to whether a cu can be applied to the limb).
Amputation.
Friable skin.
Mental health–related issues.
Cognitive impairment, e.g. dementia.
DVT (not a total contraindication, but dependent on pain and if
active treatment has been started for a period of 48 hours).
Critical limb ischaemia.
Neurological disease.
There are some conditions that may lead to inaccurate results
of the vascular assessment and may warrant onward referral
(Table5.9).
In recent years, advances in technology have resulted in new
developments for ABPI testing. Automated devices can simplify
and speed up an accurate assessment compared to traditional
Doppler testing, although not all clinical environments have
access to these devices. The latest guidance from the National
Institute for Health and Care Excellence (NICE2023) is that there
is not enough evidence to support their use as a direct alternative
to the handheld Doppler and they may need to be reserved for use
in research or in conjunction with the handheld Doppler by a
healthcare professional already experienced in the assessment of
peripheral vascular disease. At the time of writing it is noted that
a national response to the NICE guidance is being prepared by a
senior consortium of lower limb professionals.
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TABLE5.9
Doppler results.
Peripheral oedema Inaccurate results could elevate ankle brachial
Diabetes Small vessel disease– calcication of arteries will
Atherosclerosis Hardening the arteries due to disease– may lead to
Uncontrolled pain May lead to raised blood pressure and inability to
Renal disease Blood pressure uctuations may lead to
Cardiac arrhythmias Including atrial brillation– when the pulse is
Source: Adapted from Staines (2018).
Presenting conditions that may lead toinaccurate
pressure index (ABPI) through inability to
occlude the artery due to oedema.
lead to false high readings as arteries cannot
be occluded.
high ABPI.
keep the limb still to perform the procedure.
inaccuracy.
irregular may miss the incoming return of
the pulse.
HOW TOPERFORM AHANDHELD DOPPLER
Equipment needed:
Handheld Doppler 5–8 MHz (5 MHz probe for a larger limb,
8 MHz probe for a normal limb).
Ultrasound gel (alternative gels such as lubricants should
not be used).
Sphygmomanometer cu 23–33 or 31–40cm in accordance with
the leg/arm circumference.
Paper towels.
Cling lm.
Disinfectant wipes to clean and decontaminate the equipment.
Before undertaking the procedure, explain to the patient what is
going to happen. Ensure that the patient understands and knows
what is involved (Beldon2011).
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Measure theBrachial Systolic Blood Pressure
Step1
The patient should lie as at as possible for 10–15 minutes with no
external pressure on the proximal vessels (Vowden and Vowden2018).
They should avoid smoking or caeine, as this can aect the results of
the test. Lying at for 10–15 minutes removes the eect of gravity on
the blood ow and minimises hydrostatic pressure variance. If a
patient is unable to lie at due to breathing diculties, ask them to lie
as low as is tolerable. The position for the procedure should be recorded
(Young2015). Examination without resting may lead to lower ankle
systolic pressure and reduced ABPI (Vowden and Vowden 2018).
Patients should be informed that they may experience some discomfort during the procedure when the blood pressure cu tightens and
that they may ask to stop if the procedure becomes too painful.
Step2
Apply the sphygmomanometer cu rmly to the arm above the elbow
(see Figure5.13). It is important to measure the circumference of the
arm rst and select the appropriately sized cu (the bladder of the
cu should t around at least 80% of the limb but not more than
100%). If the cu does not t properly, it is likely that the reading will
be inaccurate. If the cu is too small, a considerable overestimation
can occur (Vowden and Vowden 2018). Locate the brachial artery
(with ngers) and apply contact gel on the skin to aid conduction. The
Doppler probe must be kept at 45–70° to the skin towards the patient’s
face until the arterial sign is audible and clear (Beldon2011). Do not
press the probe into the patient’s skin as it may occlude the vessel.
Step3
Keep the probe still and start to inate the cu until the audible
sound disappears. Inate a further 20 mmHg and be careful not to
move the probe from the line of the artery during deation (Vowden
and Vowden2018). A rapid deation of the cu may miss the highest
pressure and underestimate the ABPI (Vowden and Vowden2018).
Record the reading: this is the brachial systolic pressure. N.B. If the
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FIGURE5.13 Applying the sphygmomanometer cu.
patient has cardiac rhythm alterations, such as atrial brillation,
consider releasing the cu more slowly. Repeat the same procedure
on the opposite arm. Record each reading immediately so as not to
confuse readings later. Use the highest of the two values to calculate
the ABPI. Note that if a dierence of more than 15 mmHg is detected
between the two values, then a referral for vascular review is indicated
as this may be indicative of undetected PAD. It is worth noting that
before a referral it is prudent to consider rechecking.
Measure theAnkle Systolic Pressure
Step1
Cover any wounds with cling lm or lm dressing.
Step2
Locate the pedal foot pulses to assess the arteries. There are four
pedal pulses that can be used: posterior tibial artery (PTA), anterior
tibial artery (ATA), peroneal tibial artery and dorsalis pedis artery
(see Figure5.14). Palpate pedal pulses and document which ones if
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Assessment of Leg Ulceration 271
Artery
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Dorsalis pectis
artery
Medial plantar
First dorsal
metatarsal
Deep plantar
Arcuate
Dorsalis pedis
Anterior tibial
Lateral plantar
Posterior tibial
Lateral Plantar
Medial Plantar
Artery
Lateral Tarsal Artery
Dorsalis Pedis
Arcuate Artery
Deep Plantar Artery
Anterior Tibial Artery
Peroneal Artery
Posterior Tibial Artery
Posterior
tibial artery
FIGURE5.14 Arterial pulses of the foot.
any are palpable. The two most common arteries used in this
procedure are the dorsalis pedis and the posterior tibial arteries, but
studies have demonstrated that the peroneal should be included
in this test: as a smaller vessel this may be the rst one to be
occluded(Taylor and Holland1990). The dorsal pedis and anterior
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