Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Diagnostic Evaluation
  1. An Ankle Brachial Pressure Index (ABPI) measurement should be performed and interpreted by a trained practitioner as a screening tool, in conjunction with clinical assessment, to rule out the presence of peripheral arterial disease prior to the application of compression therapy.
  2. An Ankle Brachial Pressure Index (ABPI) >1.2 and <0.8 warrants referral for further vascular assessment.
  3. Prior to debridement, a client history, physical and clinical assessment, and a vascular assessment, such as an Ankle Brachial Pressure Index (ABPI), is recommended to ensure healability.