The patient has shiny ulcerations on a red base over the medial calf of the right leg. There is quite a bit of fluid drainage. He takes anticoagulants because of recurrent deep vein thrombosis. He also reports a sedentary lifestyle
How would the nurse classify this chronic wound?
a. Pressure ulcer
b. Venous stasis ulcer
c. Diabetic foot ulcer
d. Arterial ulcer
B
The location of the ulcers and the history of past deep vein thrombosis would make venous stasis ulcers the most likely classification for these wounds. They occur usually between the inside ankle and the knee, not necessarily over a bony prominence, and are typically red in color, shiny, and taut, and may even feel warm or hot. Fluid drainage can be significant. A pressure ulcer is unlikely to develop on the medial side of the calf because it is neither a bony area nor one that is likely to be an area where there is pressure. There is no indication that this patient is diabetic and the wound is not on the foot. An arterial (ischemic) ulcer tends to be dry and pale, with little drainage. Arterial ulcers are usually very painful, especially at night.
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