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Integumentary
Ulcer Characteristics
Clinical Finding | Type 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 |