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Integumentary

Ulcer Characteristics

Clinical FindingType of ulcer
Location on lower 1/3 of leg, toes, web spaces (distal toes, dorsal foot, lateral malleolus) Arterial insufficiency
Smooth edges, well defined; lack granulation tissue; tend to be deep Arterial insufficiency
Minimal exudate Arterial insufficiency
Severe pain Arterial insufficiency
Diminished or absent pulses Arterial insufficiency
Normal edema Arterial insufficiency
Decreased skin temperature Arterial insufficiency
Thin and shiny tissue; hair loss; yellow nails Arterial insufficiency
Leg elevation increases pain Arterial insufficiency
Location proximal to the medial malleolus Venous insufficiency
Irregular shape, shallow Venous insufficiency
Moderate / heavy exudate Venous insufficiency
Mild to moderate pain Venous insufficiency
Normal pulses Venous insufficiency
Increased edema Venous insufficiency
Normal skin temperature Venous insufficiency
Flaking, dry skin; brownish discoloration Venous insufficiency
Leg elevation lessens pain Venous insufficiency
Location on areas of foot susceptible to pressure of shear forces during weight bearing Neuropathic
Well-defined oval or circle; callused rim; cracked periwound tissue; little to no wound bed necrosis with good granulation Neuropathic
Low/moderate exudate Neuropathic
No pain, however dysesthesia may be reported Neuropathic
Diminished or absent pulses; unreliable ankle-brachial index with diabetes Neuropathic
Normal edema Neuropathic
Decreased skin temperature Neuropathic
Dry, inelastic, shiny skin; decreased or absent sweat and oil production Neuropathic
Loss of protective sensation Neuropathic
Created by: glopez111
 

 



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