Steps for Assessment
1. Review the medical record, including skin care flow sheet
or other skin tracking form.
2. Speak with direct care staff and the treatment nurse to
confirm conclusions from the medical record review.
3. Examine the resident and determine whether any venous or
arterial ulcers are present.
•
Key areas for venous ulcer development include the
area proximal to the lateral and medial malleolus (e.g.,
above the inner and outer ankle area).
•
Key areas for arterial ulcer development include the
distal part of the foot, dorsum or tops of the foot, or tips
and tops of the toes.
•
Venous ulcers may or may not be painful and are
typically shallow with irregular wound edges, a red
granular (e.g., bumpy) wound bed, minimal to moderate
amounts of yellow fibrinous material, and moderate to
large amounts of exudate. The surrounding tissues may
be erythematous or reddened, or appear brown-tinged
due to hemosiderin staining. Leg edema may also be
present.
•
Arterial ulcers are often painful and have a pale pink
wound bed, necrotic tissue, minimal exudate, and
minimal bleeding.
DEFINITIONS
VENOUS ULCERS
Ulcers caused by peripheral
venous disease, which most
commonly occur proximal to
the medial or lateral
malleolus, above the inner or
outer ankle, or on the lower
calf area of the leg.
ARTERIAL ULCERS
Ulcers caused by peripheral
arterial disease, which
commonly occur on the tips
and tops of the toes, tops of
the foot, or distal to the
medial malleolus.
DEFINITION
HEMOSIDERIN
An intracellular storage form
of iron; the granules consist
of an ill-defined complex of
ferric hydroxides,
polysaccharides, and
proteins having an iron
content of approximately
33% by weight. It appears as
a dark yellow-brown pigment.
M1030: Number of Venous and Arterial Ulcers (cont.)