South West Regional Wound Care Program Interdisciplinary Lower Leg Assessment Form Page 3
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3Person’s Name: ________________
ID Number: ________________
Date: ________________
LEG PAIN
Right Leg
Left Leg
Other Symptoms
Venous Symptoms
Arterial Symptoms
Other Symptoms
Venous Symptoms
Arterial Symptom
Deep bone
Pain with deep
Knife-like pain
Deep bone
Pain with deep
Knife-like pain
pain (?
palpation
Intermittent
pain (?
palpation
Intermittent
Osteomyelitis)
Pain relieved
claudication
Osteomyelitis)
Pain relieved
claudication
Pain in ulcer (?
with elevation
Increased pain
Pain in ulcer (?
with elevation
Increased pain
Infection)
Aching pain
with limb elevation
Infection)
Aching pain
with limb elevation
Known arthritic
Pain at night or
Known arthritic
Pain at night or
pain
at rest
pain
at rest
Consider referral to Family physician, pain specialist, or physiotherapist to address pain control
CIRCULATION: PULSE ASSESSMENT
Right Leg
Left Leg
Dorsalis-Pedis:
Post-Tibial:
Dorsalis-Pedis:
Post-Tibial:
Present (normal)
Present (normal)
Present (normal)
Present (normal)
Diminished
Diminished
Diminished
Diminished
Bounding
Bounding
Bounding
Bounding
Absent
Absent
Absent
Absent
CIRCULATION: ABPI
*To have been completed by a trained individual within the past six months
Right Leg
Left Leg
Dorsalis Pedis:
Post-tibial:
Dorsalis Pedis:
Post-tibial:
Brachial:
ABPI:
Brachial:
ABPI:
INTERPRETATION OF ABPI *Compression chosen based on ABPI results and whole person assessment
ABPI >1.2 or Non-Compressible Abnormal, refer for segmental compression studies
Normal = >0.9 to 1.2 Implement high compression therapy if indicated, i.e. Coban 2, Profore, Proguide, Surepress
ABPI 0.8 - 0.9 Mild ischemia (venous) – Moderate to High compression, i.e. Coban 2, Profore, Proguide, Surepress
ABPI 0.5 to 0.79 Moderate ischemia (mixed) – Light compression, i.e. Coban 2 Lite, VIscopaste, Tubigrip, refer for segmental
compression studies
ABPI 0.35 to 0.49 Moderately severe ischemia (arterial) – NO compression, URGENT refer to vascular surgeon
ABPI 0.2 to 0.34 Severe ischemia (arterial) – NO compression, URGENT refer to vascular surgeon
ABPI <0.2 Critical ischemia (arterial) – NO compression, URGENT refer to vascular surgeon
Impression:
Venous leg ulcer
Complicated by:
Lymphedema, stage ____________________
Mixed leg ulcer
Lipedema
Arterial leg ulcer
Other ____________________
Healability:
Healable
Maintenance
Non-Healable/Palliative
X
S ig n a t u r e a n d D e s ig n a t io n
SWRWCP: B.7.1_Interdisciplinary Lower Leg Assessment Form_Jan_16_2011_Rev_Jan_2014
Page 3
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