Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Comprehensive Clinical History and Physical Examination

A comprehensive clinical history and physical examination includes:

  • blood pressure measurement;
  • weight;
  • blood glucose level;
  • doppler measurement of Ankle Brachial Pressure Index (ABPI);
  • any other tests relevant to presenting patient’s condition;
  • ulcer history;
  • ulcer treatment history;
  • medical history;
  • medication;
  • bilateral limb assessment;
  • pain;
  • nutrition;
  • allergies;
  • psychosocial status (including quality of life); and
  • functional, cognitive, emotional status and ability for self-care.

The above should be documented in a structured format for a client presenting with either their first or recurrent leg ulcer and should be ongoing thereafter.