Vascular Assessment

The person is considered to have poor circulation to the lower legs if there is a combination of the following signs and symptoms:

Medical history

• History of previous pressure injuries in the lower extremities, the interventions used, and the person’s previous response to wound management.
• Risk factors that contribute to arterial insufficiency, such as elevated lipids, diabetes, family history of vascular compromise, smoking, and cardiovascular history (e.g., previous stroke, cardiac events or surgery, or previous vascular surgery).
• Increased pain in the lower extremities at rest and with movement (e.g., intermittent claudication).

Physical exam

• Diminished pedal pulses (check posterior tibial and dorsalis pedis).
• Presence of dependent rubor and pallor on elevation of the lower limbs.
• The affected lower limb is cooler, cyanotic, lacks hair, and has dystrophic nails.
• Non-invasive arterial studies (e.g., ankle brachial pressure index [ABPI], toe pressure index [TPI]). In the affected limb, an ABPI less than 0.6 or a TPI less than 0.65 is indicative of poor blood circulation in the lower extremities.

If the assessment reveals impairments in vascular status (i.e., arterial flow) in the person’s lower extremities, the person should be referred to the most responsible health-care professional or to a health-care professional with vascular expertise for further assessment and diagnostic testing of his or her lower leg pressure injuries prior to any wound intervention, or if the wound is not healing as expected after wound care management (e.g., debridement exam).