1300 - Client presents to the clinic on a referral from the primary healthcare provider for a wound to the right ankle area. The injury developed three months ago and has worsened despite topical treatment. On assessment, the wound is 5 cm x 4 cm and is shallow. The wound bed is pink with some granulation tissue; scant sanguineous drainage. Wound edges are uneven. Client reports pain only when dressing changes are performed, and the pain is rated as 5 on a scale of 0 (no pain) to 10 (severe pain). The surrounding skin on the affected foot is dry, darkened, and flaky. Capillary refill < 3 seconds. Peripheral pedal pulse 2+ on the affected foot. 3+ Ankle edema was noted in both lower extremities. The client denies leg pain during ambulation but endorses ankle swelling during the day while walking, and the only relieving factor is the application of a compression hose to both legs. The client reports applying a hot compress to the extremity but states after 2-3 applications, it worsened and became painful.
- hyperlipidemia
- daily cigarette smoker
- diabetes mellitus (type two)
- generalized anxiety disorder
- hypertension
➢ For each assessment finding below, click to specify if the finding is consistent with an arterial, venous, or diabetic ulcer. Each finding may support more than one (1) disease process
Note: Each column must have at least one (1) response option selected
- A. swelling in affected extremity
- B. pedal peripheral pulse 2+
- C. swelling relieved with compression hose
- D. denies leg pain during ambulation
- E. shallow wound bed
- F. medical history of hypertension and diabetes mellitus
- G. worsened with hot compress
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