Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Assessment
1.0. Obtain a comprehensive health history and perform physical examination of affected limb(s).
1.1. Identify the location and classification of foot ulcer(s) and measure length, width and depth of wound bed.
1.2. Assess bed of foot ulcer(s) for exudate, odour, condition of peri-ulcer skin and pain.
1.3. Assess affected limb(s) for vascular supply and facilitate appropriate diagnostic testing,
as indicated.
1.4 Assess foot ulcer(s) for infection using clinical assessment techniques, based on signs and
symptoms, and facilitate appropriate diagnostic testing, if indicated.
1.5. Assess affected limb(s) for sensory, autonomic and motor changes.
1.6. Assess affected limb(s) for elevated foot pressure, structural deformities, ability to exercise,
gait abnormality, and ill-fitting footwear and offloading devices.
1.7. Document characteristics of foot ulcer(s) after each assessment including location, classification and any abnormal findings.