How to assess a venous leg ulcer

➔ Begin with a holistic patient assessment.


• For more information on how to conduct a holistic patient assessment, look to The Wound Care Pathway.



➔ Proceed with a lower limb assessment using a validated assessment tool (i.e. Leg Ulcer Measurement Tool LUMT). 



➔ Then begin your wound assessment using a validated wound assessment tool (i.e. Triangle of wound assessment). 


• Make note of wound size, wound bed, amount and type of exudate, condition of wound edge and periwound skin and signs of infection


• Also check position of the ulcer – malleolus or gaiter area



➔ Make your assessment by checking for oedema and looking for:

Learn more about Hyperkeratosis of the lower limb.

When you are looking for ulceration in a leg, all changes in the skin (including colour and texture should be thoroughly assessed.)⁵

➔ Be sure to check for signs of venous insufficiency, by looking for:


• Oedema – measure circumference of ankle, foot and calf.


• Signs of vascular insufficiency – inspect arterial flow and perfusion.


• Signs of venous hypertension – inspect legs for varicose veins – (reticular phlebectasia), skin changes (i.e. small widened blood vessels (telangiectasia), and changes in pigmentation.

➔ You should also consider:


• Patient’s BMI (Body Mass Index) – a BMI of between 53-59 is usually when lymphedema occurs.⁶

• Other risks and complicating factors such as: patient mobility, prolonged sitting or standing, calf muscle pump, gait, comorbidities, medications, family history, etc.

How to diagnose a venous leg ulcer

➔ When you are dealing with a venous leg ulcer, it is important to also diagnose the leg to exclude arterial insufficiency. 



➔ Use the ABPIs (Ankle Brachial Pressure Index) as a means of differential diagnosis and to assess the leg for ischemia.⁷ (At a minimum, pulse palpation is mandatory – follow local policy)



➔ Be sure to measure pulse on both locations on the ankle – posterior tibial artery and dorsal pedal artery.

How to develop a treatment and care plan

➔ Once your diagnosis of the leg has excluded arterial insufficiency, you are ready to determine the need for any additions to the standard treatment planning procedure.



➔ You should proceed according to the result of your ABPI: 


• In case your ABPI is more than 0.8, arterial, involvement can be ruled out and compression therapy can be considered at 40mmHg. 


• In case your ABPI is between 0.5 and 0.8 refer for advice regarding level of compression. 


• In case your ABPI is less than 0.5 do not compress and refer immediately for vascular assessment.

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How to manage a venous leg ulcer

➔ First, prepare the wound bed by cleansing and debriding the wound to remove debris and necrotic or indolent tissue. Cleansing of the full leg with a pH-appropriate cleanser is recommended to reduce odour and to protect the skin surrounding the ulcer. If possible get the patient to shower.



➔ Be prepared to manage exudate to protect the periwound skin, as venous leg ulcers are often highly exudating. (This will reduce over time with the correct level of compression therapy).



➔ Frequently undertake a patient reported pain assessment, as leg ulcers are ranked as the most painful compared to other wounds.²

➔ Apply compression therapy for patients with active venous ulceration and an ABPI above 0.8 – and refer for vascular assessment and monitoring. (Compression therapy aims to improve venous return and reduce venous hypertension. Compression is usually graduated and can include bandages, wraps, calf pumps and compression hosiery.)^1,8

➔ Choose the correct type of compression by taking relevant factors into account: The severity of the disease, the anatomical characteristic of the leg/ankle, required frequency of applications, and the functionality of the patient: Patient preference, mobility, lifestyle and likely concordance.⁹


➔ Check for signs of infection at each dressing change, as infection and biofilm are common in venous leg ulcers. Use the IWII infection continuum and management guide.

How to choose dressing and additional therapy

➔ Choose a dressing that helps you effectively manage exudate, as venous leg ulcers are typically highly exudating.



➔ Make sure the dressing is able to conform to the wound. It should leave no gap between dressing and wound bed in order to effectively manage exudate and bacterial balance. For highly exuding wounds consider a superabsorbent dressing.

➔ Look for dressings that are atraumatic upon removal – it should not cause further damage to the wound bed or periwound skin – but should ideally help decrease pain and odour for patients. 



➔ If you suspect infection use a dressing with antimicrobial properties. 



➔ Consider adjunct therapies like NPWT when appropriate.

How to monitor progression

➔ You should monitor venous leg ulcers at least every 4 weeks. Specifically look for distortion or modification of the shape of the leg. 



➔ Measure oedema reduction or redistribution at every dressing change and action taken as needed to amend the compression regime. 



➔ In case, the wound is not healing with therapeutic compression refer to a vascular specialist, if that has not already been done. 



➔ In case ulcer has not healed after 12 weeks, reassess differential diagnosis. Also revisit holistic patient assessment to assess if factors such as low haemoglobin, immune function deficits or other co-morbid conditions are affecting healing. You should also re-consider other risk factors such as patient’s lifestyle, past compression usage, etc. 



➔ Discuss prevention strategies with patient such as skin care, life long compression hosiery, physical exercise (ankle & dorsal reflection, gait, calf muscle pump), weight control, etc. 



For patients with healed venous leg ulcers, long term compression should be considered to reduce the risk of recurrence.

For a glossary of general wound care terms consult The Wound Care Pathway: