Venous Ulcer Checklist
ASSESS
PREVENT
Trained professional or interdisciplinary team
Document patient physical / medical / surgical
history to diagnose ulcer causes and risk factors to
guide treatment plan.
On examination document clinical, etiology,
anatomic, pathophysiology (CEAP) score
Lower leg edema or venous insufficiency
Personal / family history of deep vein
thrombosis or pulmonary embolism
Prior vein damage; malignancy, clot
disorder, medications, surgery or trauma
Medial lower leg dermatitis, increased dermal
thickness, crust, hardness/fibrosis , dark
color (hemosiderin), ache/pain
Slow healing risk: VU > 5 cm2, persists > 6
month; patient obese, > 50 year age, male
Differential diagnosis
Ankle/brachial Index < 0.8 or local TcPO2 <30
mmHg: assess for arterial cause.
Vein refill time > 20 seconds: likely venous
Local heat  >1.1○ C: suspect infection
Local hair growth suggests non-arterial cause
Document, address patient / family goals as feasible
Document progress regularly. Use reliable, valid
measures of ulcer length x width to estimate area
&/or use a standardized edema measure.
Ensure formal assessments are accessible to
those providing or consulting on VU care
.
Improve Patient Outcomes
+
HEAL
Patient, family and all care providers
Trained staff address patient goals and risk factors to
prevent VU or improve edema and venous return.
Coach patient on elevating foot above heart, flexing
ankles, tip toe exercises, walking, smoking cessation.
Multilayer sustained, elastic high-compression
bandages, stockings or tubular bandages afford
similar VU outcomes, better than single layer
compression systems.
Two-layer compression improves comfort and
quality of life more than 4 layer compression
Elastic is better than inelastic compression.
Unna’s Boot is better than no compression and is
improved by adding an elastic layer (Duke Boot)
Pneumatic compression, inelastic strapping
device or standardized lymphatic massage are
each more effective than no compression
Match compression to patient needs and calf size
Moisturize dry skin and protect from irritation,
sensitization or chemical or physical injury.
Use nutrition, circulation, infection diagnostic
consult(s) as needed to identify and reduce VU risk
Manage lower leg skin infection, inflammation, edema
and circulation consistent with patient and family
goals and professional consult advice as feasible.
Be alert to patient allergies & sensitization reactions
and provide patient-appropriate care.
=
Complete venous ulcer (VU) team
Treat patient and VU to improve healing, pain, quality of life
costs of care and prevent recurrence and/or hospitalization
Continue or implement all VU prevention measures
Perform weekly community nursing, coaching and/or peer
support to encourage consistent elevation, proper calf
muscle exercise, elastic compression use to heal VU and to
prevent VU recurrence or deterioration.
Use medium compression elastic stockings if feasible.
They are worn more consistently than high compression
elastic stockings, with similar VU recurrence rates.
Apply moisture-sealing VU dressings beneath elastic
compression to improve VU healing, pain, application time
compared to short-stretch or Unna’s Boot compression.
Add primary absorbent dressing if needed to prolong wear
Manage venous return per institutional protocols to meet
patient/ family needs and goals as feasible
Compress Elevate Exercise calf  Other________
Cleanse VU (4-15 psi) with safe non-antimicrobial fluid
Debride non-viable tissue using (check one):
AutolyticEnzymatic Surgical  Other__________
Manage VU pain and debridement pain as needed/feasible
Use antimicrobial only if VU has clinical infection signs/
symptoms: increased pain, heat, odor, color, edema
If VU area decreases less than 40% in 3 weeks it is likely
not on a healing path. Re-evaluate diagnosis &/or care plan.
If VU shows no healing in 4 weeks consider effective vein
surgery or patient-appropriate adjunctive treatment +above
above care.