The vascular assessment will answer the question “Does the wound have enough blood supply to heal?”
Healthy tissue is bright, beefy red, shiny, and granular with a velvety appearance. Tissue with poor
vascular supply is pale pink or blanched to dull, dusky red color.

Physical vascular assessment includes: peripheral pulses, temperature, presence or absence of hair,
mild to severe pain, rest pain, edema, and gangrene. The vascular assessment should also include:

Pallor: White, pale, blanched color of a limb when in the upright position.

Rubor: Dark purple to bright red color of a limb when in a dependent position.

Intermittent claudication: Cramping or fatigue of major muscle groups in one or both lower extremities that is reproducible upon walking a  specific distance. This suggests intermittent claudication and is caused by muscle ischemia.

Mottling or mottled skin: Irregular patchy skin coloring. Refers specifically related to blood
vessel changes in the skin which cause the patchy appearance. This may indicate
vascular insufficiency.

Capillary refill: The measurement of the rate of blood refill in empty capillaries . Measured
by pressing a nail bed or area of tissue until it turns white and then timing until the
return of color once the pressure is released. Normal refill time is less than 2 seconds.

Diagnostic studies for vascular assessment:
Transcutaneous oxygen measurement (TCOM)
Ankle brachial index (ABI)
Arterial duplex scan
Arteriogram
Magnetic Resonance Arteriogram (MRA)

Document a full patient history including:

Initiating event and the duration of the wound

Previous treatments and their outcomes

Diabetes control and prior complications

Medical conditions that may interfere with wound healing

Medications that may interfere with wound healing

Underlying pathophysiology   

Psycho-social barriers to wound healing

Severity of pain

Other Important Wound Documentation

Routine skin assessment and care

Moisture management

Nutritional status

Change in clinical status or wound healing progress

Education and follow up with the patient, family, and caregivers

Discuss family adherence to plan of care

Repositioning and turning schedules

Pressure-reducing support surfaces (both bed and chair)

Document referral to specialist and/or programs including:

                Nutritional management

                Diabetes management

                Smoking cessation

                Vascular surgeon

                Interventional Radiologist

                Allergist

                Infectious Disease

A. What is the underlying etiology contributing to the wound site?

Neuropathic, diabetic, end-stage renal disease, spinal cord injury, paraplegic, ischemic/pressure injury, dyspnea.

B. Where is the wound located anatomically?

Pressure points include: occiput (back of head), scapula, spine, elbow, sacrococcygeal, trocanter, ischial tuberosities, malleolus (ankle), heel.

Friction sites may include gluteal folds, under the abdominal pannus, any skin fold, under breasts, axilla, groin, buttocks (espcially if using briefs), heels.

Document in relation to head, feet, front, or back. Commonly used terms include: proximal/distal; superior/inferior; medial/lateral; anterior/posterior; dorsal/plantar.

C. What do the wound bed and wound edges look like?

Clean, raised, rolled, curled, smooth flat, irregular, clearly defined, epibole.

D. What size and shape is the wound?

Round, oval, semi-circular, T-shaped, rectangular, punched-out. Depth may be full thickness, partial thickness, unable to be assessed.

E. What kind of drainage is present, amount, color, and odor?

Serous, sanguinous, serosanguinous, purulent, tan, opaque, clear, cloudy. Odor may be foul or sweet, “yeasty”

F. What is the condition of the surrounding skin?

Smooth, glossy, moist, blistery, weepy, “woody”, intact, healthy, erythermatous, ecchymotic, macerated, dry callus, hyperpigmentation.

Grade 0: No ulcer in a high risk foot.

Grade 1: Superficial ulcer involving the full skin thickness but not underlying tissues.

Grade 2: Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation.

Grade 3: Deep ulcer with cellulitis or abscess formation, often with osteomyelitis.

Grade 4: Localized gangrene.

Grade 5: Extensive gangrene involving the whole foot.

Wagner, F., Levin, M., & O’Neal, L., 1983. Supplement: algorithms of foot care. In The Diabetic Foot. 3 rd ed. St. Louis, MO, CV. Mosby, 1983, p. 291–

302

        Pre-albumin, albumin, transferrin levels

Use of vasoconstrictive agents

Mention if the patient is “too unstable to turn” or has to be “turned less often”

Days in bed and days without nutrition

Discuss low body mass index on admission

Discuss and document that you have discussed skin failure with the patient, family, and caregivers.

Langemo D, Brown G Skin Fails Too, Acute, Chronic, and End-Stage Skin Failure. Advances in Skin Wound Care. 2006 May;19(4):206-212.