• An assessment should be carried out by a healthcare professional trained in leg ulcer management.
• Carry out Doppler studies to exclude arterial insufficiency.
• Ask about pain (site, nature, severity), odour, and discharge.
• Examine the legs for oedema and venous eczema.
• Look for signs of an infected leg ulcer such as:
• Enlarging ulcer.
• Increased exudate or pain.
• Pyrexia.
• Foul odour.
• Cellulitis — surrounding skin is red, hot, and non-scaling.
• Inspect and record details about the ulcer, to compare at follow up in order to determine how well the ulcer is healing. Assess:
• Size and depth — trace out the ulcer margin onto a transparent sheet, or if possible and appropriate, a photograph may be helpful. Examine to assess the depth of the ulcer.
• Wound bed — look for granulation, and fibrous or necrotic tissue which may need to be removed to allow healing. Look for exudate to help determine which dressing is needed.
• The ulcer edge often give a good indication of progress and should be carefully documented (for example shallow, epithelialising, punched out).
• The position of the ulcer(s) should be clearly described.
• Assess the impact that the symptoms are having on the person's quality of life. For example, can they move around and carry out normal activities of daily living such as shopping, housework, or employment?
• Assess risk factors (such as immobility or obesity) and comorbidities (such as diabetes mellitus or rheumatoid arthritis) which need treatment or referral to promote ulcer healing.

In depth

• A Doppler assessment of both legs and interpretation should be carried out on all people by an appropriately trained healthcare professional.
• An ankle brachial pressure index (ABPI) involves the measurement of a person's systolic blood pressure at their ankle and arm (brachial) using a Doppler machine. The ABPI provides an index of vessel competency by measuring the ratio of systolic blood pressure at the ankle to that in the arm, with a value of 1 being normal. When interpreting ABPI in a person with venous ulcer, a ratio of:
• Less than 0.5 indicates severe arterial insufficiency and compression treatment is contraindicated. Refer urgently to a specialist vascular clinic for further assessment.
• Between 0.5 and 0.8 indicates that the person has arterial disease. Refer to a specialist vascular clinic for further assessment. Compression bandaging should generally be avoided. However, reduced compression can be used under strict supervision (assess progress daily) if the ulcer is clinically venous and the healthcare professional has sufficient experience.
• Greater than 0.8 indicates that graduated compression bandages may be safely applied.
• Be aware that the ABPI may decrease after the initial measurement. Arterial disease may develop in people with venous disease, and the ABPI will also reduce with increasing age.
• People with diabetes mellitus, atherosclerotic disease, rheumatoid arthritis, and systemic vasculitis should be referred for a specialist assessment as the ABPI in these people may not be reliable. These conditions may give falsely high (and misleading) ABPI readings due to calcification of the blood vessels.

In depth