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Nursing Best Practice Guideline<br />
Location of Ulcers<br />
Gaiter Region<br />
Leg<br />
RT LT<br />
Dorsum of Foot<br />
Digits<br />
Leg<br />
RT LT<br />
Beneath Calluses<br />
Leg<br />
RT LT<br />
Edema<br />
Other<br />
Characteristics<br />
• Pitting<br />
Mild (1+)<br />
Moderate (2+)<br />
Severe (3+)<br />
Very Severe (4+)<br />
• Non pitting<br />
• Edema of toes<br />
Varicose veins<br />
Fixed ankle joint<br />
Dependency<br />
edema<br />
Foot deformity<br />
• Hammer toes<br />
• Prominent<br />
metatarsal heads<br />
• Charcot joint<br />
93<br />
Probable<br />
Etiology<br />
Venous<br />
Arterial<br />
Diabetic<br />
Neuropathy<br />
Circumference (Right Leg)<br />
Ankle _____ Cm Calf _____ Cm<br />
Sensation (Right)<br />
(Clients with suspected neuropathy)<br />
Perception of Pain<br />
❏ Normal ❏ Increased<br />
❏ Decreased ❏ Absent<br />
Perception of Temperature<br />
Hot ❏ Yes ❏ No<br />
Cold ❏ Yes ❏ No<br />
Perception of Touch<br />
❏ Normal ❏ Increased<br />
❏ Decreased ❏ Absent<br />
Ankle Brachial Pressure Index (Right)<br />
Brachial Systolic _____<br />
Dorsalis Pedis ________ Anterior Tibial _____<br />
Posterior Tibial _______ Peroneal _____<br />
ABPI _______<br />
Circumference (Left Leg)<br />
Ankle _____ Cm Calf _____ Cm<br />
Sensation (Left)<br />
(Clients with suspected neuropathy)<br />
Perception of Pain<br />
❏ Normal ❏ Increased<br />
❏ Decreased ❏ Absent<br />
Perception of Temperature<br />
Hot ❏ Yes ❏ No<br />
Cold ❏ Yes ❏ No<br />
Perception of Touch<br />
❏ Normal ❏ Increased<br />
❏ Decreased ❏ Absent<br />
Ankle Brachial Pressure Index (Left)<br />
Brachial Systolic _____<br />
Dorsalis Pedis ________ Anterior Tibial _____<br />
Posterior Tibial _______ Peroneal _____<br />
ABPI _______<br />
© Loeb Health Research Institute, Clinical Epidemiology Unit
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