Development of an accurate nursing program based on function in chronic venous leg ulcers: protocol for matching function status with nursing interventions using the Delphi survey

Assessment	0	1	2	3	4
A1.Exudate type	None	Serosanguineous	Serous	Seropurulent	Purulent
A2.Exudate amount	None	Scant	Small	Moderate	Copious
A3.Size (length×width)	Healed	<2.5 cm²	2.5–5.0 cm²	5.1–10.0 cm²	≥10.1 cm²
A4.Depth	Healed	Partial thickness skin loss	Full thickness	Tendon/joint capsule visible	Probes to bone
A5.Undermining (greatest at _o’clock)	0 cm	>0–0.4 cm	>0.4–0.9 cm	>0.9–1.4 cm	>1.5 cm
A6.Necrotic tissue type	None	Loose white to yellow slough	Attached white to yellow slough or fibrin	Soft grey to black eschar	Hard dry black eschar
A7.Necrotic tissue amount	None visible	1–25% of wound bed covered	26–50% of wound bed covered	51–75% of wound bed covered	76–100% of wound bed covered
A8.Granulation tissue type	Healed	Bright beefy red	Dusky pink	Pale	Absent
A10.Edges	Healed	≥50% advancing border of epithelium or indistinct borders	<50% advancing border of epithelium	Attached, no advancing border of epithelium	Unattached or undermined
A11.Periulcer skin viability	None	One only	Two or three	Four or five	Six or more factors
A12.Leg edema type	None	Nonpitting or firmness	Pitting	Fibrosis or lipodermatosclerosis	Indurated
A13.Leg edema location	None	Localized periulcer	Foot, including ankle	To mid-calf	To knee
A14.Assessment of bioburden	Healed	Lightly colonized	Heavily colonized	Localized infection	Systemic infection
B1.Pain amount	None	>0–2	>2–4	>4–7	>7
B2.Pain frequency	None	Occasional	Position dependent	Constant	Disturbs sleep
B3.Quality of life	Delighted	Satisfied	Mixed	Dissatisfied	Terrible

Low risk	Medium risk	High risk
All the factors below must be present Review annually	Ankle–brachial pressure index (ABIP) = 0.81–1.3 With accompanying score of 2 or more Review every 6 months	If any one risk factor below is present Review every 3 months
ABIP 0.81–1.3	Smoker	ABIP<0.81–1.3
Mobile	Age, 70+	Diabetes
Good cognitive ability	Cardiac disease	Immobile/limited mobility
No complications	Cerebral vascular accident	Small vessel disease (i.e., diabetes)
Patient has knowledge of early symptoms of peripheral arterial disease (PAD)	Transient ischemic attack Hypertension	Angioplasty/bypass (lower limbs)
Patient has contact numbers if there are any concerns	Comorbidities (learning needs, cognitive impairment, drug/alcohol dependency, and mental illness)	Inflammatory conditions, i.e., rheumatoid arthritis Systematic lupus erythematous Intermittent claudication Unilateral amputee (PAD)

ABPI	>1.3	0.90–1.30	0.81–0.89	0.51–0.8	<0.5
Result	Abnormal vessel hardening	Normal	Abnormal	Significant ischemia	Severe ischemia