South West Regional Wound Care Program Interdisciplinary Lower Leg Assessment Form
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1
2
3Person’s Name:
South West Regional Wound Care Program
ID Number:
Interdisciplinary Lower Leg Assessment Form
Assessment Date:
EDEMA
Right Leg
Left Leg
Date of Onset:
Date of 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 10 –15 seconds
Description: Press finger into edema x 10 –15 seconds
Pitting:
1+ = 0 - ¼”
2+ = ¼” – ½”
3+ = ½ - 1”
Pitting:
1+ = 0 - ¼”
2+ = ¼” – ½”
3+ = ½ - 1”
4+ = takes several minutes to rebound
4+ = takes several minutes to rebound
Non-Pitting
Brawny Induration
Non-Pitting
Brawny Induration
Edema 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 use of compression stockings
Previous use of 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: _____________________
LYMPHEDEMA
Right Leg
Left Leg
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. Edema may be pitting.
limb elevation. Edema may be pitting.
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.
LIPEDEMA ASSESSMENT
Right Leg
Left Leg
Lipedema S&S
Lipedema S&S
“Diet resistant” fat deposits in legs bilaterally with symmetry,
“Diet resistant” fat deposits in legs bilaterally with symmetry,
with no edema of feet.
with no edema of feet.
Sharp demarcation between normal and abnormal tissue at
Sharp demarcation between normal and abnormal tissue at
the ankle giving “pantaloon” appearance.
the ankle giving “pantaloon” appearance.
Fatty pads anterior to lateral malleolus & between Achilles
Fatty pads anterior to lateral malleolus & between Achilles
tendon and medial malleolus.
tendon and medial malleolus.
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 Wound Care Specialist/ET Nurse for assessment re compression therapy
Refer to PT for ankle/calf-muscle pump training
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