Question

A nurse is admitting a client who has a leg ulcer and a history of diabetes. Which of the following focused assessments should the nurse use to help differentiate between an arterial ulcer and venous stasis ulcer?

a) Presence of granulation tissue
b) Skin color and temperature
c) Wound drainage characteristics
d) Edema assessment

Answer 1

To differentiate between arterial and venous ulcers, the nurse should assess skin color and temperature, wound drainage characteristics, and the presence of edema, as these factors vary significantly between the two types of ulcers.

Step-by-step explanation:

To differentiate between an arterial ulcer and a venous stasis ulcer in a client with a leg ulcer and a history of diabetes, the nurse should focus on the skin color and temperature, wound drainage characteristics, and the presence of edema. Arterial ulcers are often associated with poor arterial blood flow and can present with cool skin temperature, minimal wound drainage, and a pale or necrotic (dead tissue) appearance of the wound. In contrast, venous stasis ulcers involve issues with venous return and are usually accompanied by warmer skin temperature, heavy exudate or wound drainage, and the presence of significant edema. While granulation tissue may be present in both types of ulcers, its presence alone is not as useful for distinguishing between arterial and venous ulcers.

Therefore, the focused assessments that can help differentiate between the two types of ulcers are:

• Skin color and temperature
• Wound drainage characteristics
• Edema assessment