A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting to note that the ulcer:
A. Has a pale colored base.
B. Is deep, with even edges.
C. Has little granulation tissue.
D. Has brown pigmentation around it.
Correct Answer: D. Has brown pigmentation around it.
Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and granulation tissue is evident. The skin has a brown pigmentation from the accumulation of metabolic waste products resulting from venous stasis. The client also exhibits peripheral edema.
Option A: Necrotic-base ulcers have a black appearance and are non-viable, indicating a peripheral arterial disease or an infection. Fibrotic-base ulcers have a white to yellowish stringy appearance and tend to halt the formation of the granulation tissue. Granular-base ulcers have a beefy red appearance and indicate a positive healing potential.
Option B: In the visual assessment of the wound, we are looking for any possible erythemas, edema, fluid discharges, crepitations, or abscess collections. Inspect wound edges for any possible formation of hyperkeratotic tissues which tends to halt the tissue healing. A hyperkeratotic border results from increased stress on the tissue; therefore, the focal pressure should be evaluated.
Option C: This is due to tissue malnutrition, and thus an arterial problem. Quantitative measurements should be checked at every clinic visit. A comparison of the wound dimensions, including the width, length, and depth over time allows for the evaluation of the wound contracture. Ulceration discharge cultures can be obtained to target antibiotic therapy in the presence of an infection.
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