Lower limb assessment

Chronic venous disease is a common problem that is often overlooked by healthcare practitioners.

Article by Aby Mitchell and Scott Elbourne

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Venous insufficiency is an impaired flow of blood through the veins caused by valve incompetence (where the valves are unable to close completely) (Woods, 2019). Blood leaks back through the valve and pools in the superficial veins increasing pressure, which can further weaken the valves and cause irreparable damage. Incompetent valves in the leg can cause venous insufficiency (Figure 1).

Chronic venous disease is a common problem that is often overlooked by healthcare practitioners. It is estimated to affect as much as 30% of the adult population, although this is difficult to calculate given the significant rate of under-diagnosis (Radak et al, 2016). The main risk factors of chronic venous insufficiency are older age and obesity. 

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Risks and complications

Venous insufficiency includes a broad spectrum of venous complaints which range from telangiectasias or ‘spider veins’ (named for their spider web appearance) and varicose veins, to chronic venous ulcers and deep vein thrombosis (Ballard and Bergan, 2000). Women are more likely than men to have varicose veins (Ballard and Bergan, 2000). The risk factors for venous insufficiency include:

  • increasing age
  • genetics
  • occupation (prolonged standing or heavy lifting),
  • pregnancy
  • diet; some evidence suggests that a western diet of reduced fibre and refined foods leads to constipation and intra-abdominal pressure from straining is transmitted to the veins in the legs (Ballard and Bergan, 2000)
  • obesity
  • smoking
  • reduced mobility
  • haematological factors (Woods, 2019).

Increased venous pressure over time leads to a chronic inflammatory response, which can cause the breakdown of tissue resulting in venous leg ulceration (Wounds UK, 2016).

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Early assessment, diagnosis and intervention is essential to reduce the burden of chronic venous insufficiency and improve quality of life. The CEAP (Clinical-Etiological-Anatomical-Pathophysiological) classification tool is a standardised method used in the management of chronic venous insufficiency (Eklöf et al, 2004) (Table 1). Originally established as a tool to assess for recurrent varicose veins, it identifies early signs of venous disease. The tool was modified in 2004 to include chronic venous disorders. CEAP is a descriptive classification and can be used in conjunction with other venous severity scoring tools.


Table 1. CEAP classification of venous disease
CEAP classification of chronic venous disease Clinical classification
C0 no visible or palpable signs of venous disease
C1 telangiectasias or reticular veins
C2 varicose veins
C3 oedema
C4a pigmentation or eczema
C4b lipodermatosclerosis or atrophie blanche
C5 healed venous ulcer
C6 active venous ulcer
From: Eklöf et al, 2004
Assessment procedure
  1. Confirm the

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  • handheld Doppler
  • multiple size blood pressure cuffs (to accommodate different limb sizes)
  • manual sphygmomanometer
  • Doppler gel
  • clean film (to cover leg ulcers and/or wounds if present)
  • gloves and apron
  • documentation

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Procedure for ankle-brachial pressure assessment:

  1. Confirm the patient's identity, explain and discuss the full procedure and obtain consent
  2. Wash hands and put on apron and gloves
  3. Help the patient to lie down. To record the best resting ankle brachial pressure index the patient should be asked to remain as still as possible for 30 minutes. This is a crucial part of the assessment and should not be rushed (Moffatt et al, 2007; Whayman, 2014)
  4. Ensure the patient is lying as flat as possible to reduce hydrostatic pressure inaccuracies, which can lead to falsely high Ankle-brachial pressure index readings. If the patient is unable to lie flat, try to bring their legs as close to heart level as possible. Document the position of the patient to ensure consistency for future readings
  5. Observe the lower limb for any previous leg ulcer scars and ask the patient about their venous history. Check whether

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NMC proficiencies

Nursing and Midwifery Council: standards of proficiency for registered nurses

Part 1: Procedures for assessing people’s needs for person-centred care

1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages

Part 2: Procedures for the planning, provision and management of person-centred nursing care

4. Use evidence-based, best practice approaches for meeting the needs for care and support with hygiene and the maintenance of skin integrity, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions

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Ballard J, Bergan J. Chronic venous insufficiency: diagnosis and treatment. London: Springer–Verlag; 2000 

Brodovicz KG, McNaughton K, Uemura N et al. Reliability and feasibility of methods to quantitatively assess peripheral edema. Clin Med Res. 2009;7(1-2):21–31. https://doi.org/10.3121/cmr.2009.819 

Clarke GH, Vasdekis SN, Hobbs JT, Nicolaides AN. Venous wall function in the pathogenesis of varicose veins. Surgery. 1992;111(4):402–408 

Eklöf B, Rutherford RB, Bergan JJ et al. Revision of the CEAP classification for chronic venous disorders: a consensus statement. J Vasc Surg. 2004;40(6):1248-1252. https://doi.org/10.1016/j.jvs.2004.09.027 

Londero LS, Lindholt JS, Thomsen MD, Hoegh A. Pulse palpation is an effective method for population-based screening to exclude peripheral arterial disease. J Vasc Surg. 2016;63(5):1305–1310. https://doi.org/10.1016/j.jvs.2015.11.044 

Matic P, Jolic S, Tanaskovic S, Soldatovic I et al. Chronic venous disease and comorbidities. Angiology. 2015;66(6):539–544. https://doi.org/10.1177/0003319714541988

Moffatt C. Martin R, Smithdale R. Leg ulcer management: Essential clinical skills for nurses. Oxford: Blackwell; 2007 

Nakano LCU, Cacione DG, Baptista-Silva JCC, Flumignan RLG. Treatment for telangiectasias and reticular veins. Protocol for Cochrane review. Cochrane Database Syst Rev. 2017;7: CD012723. https://doi.org/10.1002/14651858.CD012723 

National Institute for Health and Care Excellence (NICE). Varicose veins: diagnosis and management. 2013.

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