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272 ASSESSMENT OF LEG ULCERATION
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tibialpulses are from the same artery, so choose one or the other.
These are easier to access when the blood pressure cu is applied
to the leg.
Step2
Apply the cu rmly at the ankle just above the malleolus. Placing
the cu above the ankle will elevate the pressure and the ABPI
(Vowden and Vowden2018) (see Figure5.15). Ensure that the cu is
the right size for the ankle circumference.
Step3
Examine the foot and apply contact gel. Continue as for the brachial
pressure and record in the same way. Remember that the foot arteries
are not parallel with the skin and sometimes the probe must be
adjusted to have a clear signal. Repeat this step for at least two of the
pedal pulses. If the pulse is irregular, a slow deation of the cu will
help with accuracy.
FIGURE5.15 Lower limb cu position. Courtesy of Accelerate.
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Assessment of Leg Ulceration 273
anklesystolic BP
ABPI
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Step4
Note the mmHg at the point of the sound returning (when the pulse
becomes audible again). This is the absolute pressure and inclusion
of this in the documentation is important, as it is an indicator of overall perfusion to the limb.
Step5
Note down the sounds– these are as valuable as the ABPI measurement.
Triphasic signal – this is represented by three sounds together
very quickly and indicates that the arteries are working well and
the artery has good elasticity. There are three parts to the waveform that can be seen visually if the Doppler device has a display
window or heard if the transmission is clear (Figure5.16).
Biphasic signal– this can be recognised as two sounds heard
together and indicates that the arteries are losing some of their
elasticity, which may be due to the ageing process. There are only
two parts to this waveform visually.
Monophasic signal– A single almost ‘banging’ sound indicates
the presence of advanced arterial disease and the artery will have
little or no elasticity in the vessel.
Calculation andInterpretation ofthe Ankle Brachial Pressure Index
The ABPI for each leg is calculated separately by taking the highest
reading of the foot pulse readings and dividing by the highest of the
brachial readings:
The ABPI values are reported numerically, for example 0.82 or
1.30, which indicates to the assessing clinician that the patient had
an arterial ow of oxygenated blood of approximately 82% or 130%.
Compression therapy may be safely used in venous leg ulcer patients
with an ABPI >0.8 (Table5.10).
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brachialsystolicBP
=
(a)
(b)
(c)
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274 ASSESSMENT OF LEG ULCERATION
Systole
Late
Zero
flow
Baseline
Diastole
Systole
Diastole
Zero
flow
Baseline
Early
Early
Diastole
FIGURE5.16 Waveforms. (a) Triphasic; (b) biphasic; (c) monophasic.
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TABLE5.10
for
compression therapy.
ABPI = 1.01–1.3 No indicators of
ABPI=0.81–1.0 Mild
ABPI=0.51–0.8 Signicant
<0.5 Severe arterial disease No compression– urgent
ABPI
ABPI >1.3
a
A high ABPI may not always be indicative of peripheral vascular disease, but could
be a false high from poor technique. A toe Doppler will be able to conrm the presence
of arterial disease if calcication in the arteries has rendered them dicult to
compress. Calcication does not usually aect the smaller vessels in the toes
(Whayman2014). It is also useful to consider the absolute pressures as an indicator
ofperfusion.
Source: Adapted from Harding etal. (2015).
Ankle brachial pressure index (ABPI) indicators
Apply high levels of
peripheral
vascular disease
peripheral disease
arterial disease
a
Measure toe pressures
or refer to specialist
compression therapy
May have high levels of
compression therapy–
monitor ABPI
May have reduced
compression– refer to
specialist nurse/
vascular
referral to vascular
May have compression
therapy– liaise with
specialist nurse/
vascular
ABPI is a useful test to determine arterial suciency. It is
important that healthcare professionals understand normal values so
that abnormal values can be recognised.
Medical factors that may aect the patient’s ability to undergo
ABPI assessment include:
DVT or suspected DVT.
Cellulitis.
Lymph node clearance.
Amputation (the automated ABPI device has an amputation
function).
Surgery to arm/leg.
Friable skin.
Mental health–related issues.
Dementia.
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Neurological disease (this may aect the patient’s ability to
stay still).
Cancer- related treatment.
Remember that when undertaking ABPI assessment, practitioners should always refer to their own local protocol, as there are local
variances between clinical services.
RED FLAGS FORTHE URGENT TREATMENT OF
PATIENTS WITHVENOUS LEG ULCERS
Infection of the leg or foot, identied by symptoms of increasing
pain, redness, oedema and local heat with purulent discharge.
Critical limb- threatening ischaemia.
Suspected untreated DVT.
Suspected skin malignancy.
REASSESSMENT ANDRECURRENCE
Leg ulcer assessment should be an ongoing process until the wound
is healed. When the wound is healed, maintenance and prevention of
recurrence are vital (Wounds UK 2016). The recurrence rate in
venous leg ulcers is estimated to be as high as 50.4% within the rst
12 months (Finlayson et al. 2018). Doppler ABPI reassessment is
essential every three months, or more frequently if changes in the
lower limb are observed.
CONCLUSION
Good assessment and history taking are pivotal to decision- making,
diagnosis, treatment and partnership working with patients with leg
ulcers. Communication between healthcare professionals and patients
is essential to gain trust, partnership and understanding. Consideration
must be given to patients with any additional vision, hearing or
literacy needs. It is essential for practitioners to have cultural
competence and awareness to ensure that patients’ cultural needs and
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Assessment of Leg Ulceration 277
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beliefs are met. Assessment is not just something that happens at the
beginning of treatment, it should be ongoing throughout. Identifying
leg ulcer aetiology, causes and risk factors is essential to ensure that
treatment options and strategies are appropriate and eective. Having
an in-
depth understanding of the patient you are working with will
help you nd the most successful treatments.
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personalised- care.pdf
neuropathy/causes
conditions/skin- hair- and- nails/varicose- eczema
ulcer- venous
conditions/
Seminars
Journal
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