Thorough assessment is needed to identify underlying disease with the aim of treating the disease along with the ulcer and to rule out alternative diagnosis EWMA Statement 5.2a: All patients presenting with lower leg ulceration must receive a comprehensive assessment.
- Assess the site of the ulcer. Venous ulcers are typically situated below the knee and above the foot (this area is known as the gaiter area) or around the malleolus. These ulcers are usually shallow with gently sloping, irregular edges. Check for any undermining, rolled or raised edges as this may indicate a possible malignancy.
- Record details about the ulcer, such as the size and depth. If possible, take a photograph and measure the wound. Note the type of tissue on the wound bed
- Granulating tissue is red, healthy tissue
- Hypergranulation tissue can be seen as over granulating or proud flesh
- Epithelializing tissue are tightly packed cells that grow over granulation tissue to restore the epidermis. They are pink in colour and can be seen at the wound edges or as white/pink islands in the wound bed where they are generating from hair follicle sites. This tissue is evidence of healing
- Slough this is non-viable tissue which can be soft or hard and dry and is usually yellow in colour
- Necrotic tissue presents as black or brown in colour and this is non-viable tissue
- Infected tissue tends to be green in colour (or could be bright green if Pseudomonas Aeruginosa is present). Document percentage of each tissue type in wound
- Signs of infection include an enlarging ulcer accompanied by a changing, new or foul odour and there may be increased pain or exudate. A localised infection will be contained within the wound bed/peri-ulcer skin, whereas a cellulitis is an infection that is seen to be spreading up the limb. BILATERAL CELLULITIS IS VERY RARE AND MAY BE CONFUSED WITH BILATERAL INFECTED VARICOSE ECZEMA
- Assess for peripheral vascular disease (this needs to be done prior to the commencement of compression therapy) - look for hair loss, pallor, coldness and dusky in appearance on the lower leg. Assess capillary refill (>4 seconds is indicative of arterial insufficiency).
- Inspect the peri-wound area to assess for maceration, cellulitis, oedema, erythema, or varicose eczema.