Medical Surgical Peripheral Vascular Disease #5

Question

The nurse is caring for a client with an open lower extremity leg ulcer. The wound margins are irregular, the wound bed is red, and is draining moderate amounts of thick exudate. The nurse documents which type of ulcer?

Answers

  1. Arterial ulcer
    • Rationale:

      This answer is not correct because this client has venous insufficiency since the wound is irregularly shaped. Arterial insufficiency has symptoms including decreased pulse or pulselessness, pain, thin, shiny skin, thick toenails, hairlessness, and a round, punched-out wound ulcer.

  2. Venous ulcer
    • Rationale:

      This answer is correct because venous insufficiency is when there is decreased blood flow in the venous system as blood is returned from the peripheral extremities, most often the legs and feet. Various symptoms are associated with this condition, including edema, darkening of the skin, scaly, discolored, thick skin on the legs, and irregularly shaped ulcers or wounds on the feet, ankles, or legs. In contrast, arterial insufficiency has symptoms including decreased pulse or pulselessness, pain, thin, shiny skin, thick toenails, hairlessness, and a round, punched-out wound ulcer.

  3. Edema ulcer
    • Rationale:

      This answer is not correct because there is no indication of edema surrounding this ulcer. Nevertheless, the irregularity of the edges of the ulcer indicates it is a venous ulcer. Symptoms associated with venous insufficiency include edema, darkening of the skin, scaly, discolored, thick skin on the legs, and irregularly shaped ulcers or wounds on the feet, ankles, or legs.

  4. Wound ulcer
    • Rationale:

      This answer is not correct because “wound ulcer” is not specific enough. The irregularity of the edges of the ulcer indicates it is a venous ulcer. Symptoms associated with venous insufficiency include edema, darkening of the skin, scaly, discolored, thick skin on the legs, and irregularly shaped ulcers or wounds on the feet, ankles, or legs.

Overview

Venous insufficiency is when there is decreased blood flow in the venous system as blood is returned from the peripheral extremities, most often the legs and feet. Venous ulcers are characteristically irregular wounds to the lower extremity.

Explanation

Learning Outcomes

Venous insufficiency is when there is decreased blood flow in the venous system as blood is returned from the peripheral extremities, most often the legs and feet. Various symptoms are associated with this condition, including edema, darkening of the skin, scaly, discolored, thick skin on the legs, and irregularly shaped ulcers or wounds on the feet, ankles, or legs. The nurse should be able to identify the differences between venous insufficiency and arterial insufficiency. Arterial insufficiency has symptoms including decreased pulse or pulselessness, pain, thin, shiny skin, thick toenails, hairlessness, and a round, punched-out wound ulcer.

Test Taking Tip

Remember: Venous ulcers are Very irregular.

Video Rationale