An older adult patient has an open, draining wound on the lower medial aspect of the right leg. The skin surrounding the wound is reddish brown with surrounding erythema and edem
a. Based on this information, the nurse edits the patient's care plan to include impaired skin integrity:
a. related to altered venous circulation.
b. peripheral related to arterial insufficiency.
c. related to diabetic neuropathy.
d. open wound related to pressure ulcer.
A
Venous ulcers are usually on the medial aspect of the lower leg, with flat or shallow craters and irregular borders, accompanied by varicosities, liposclerosis (brown ruddy color and thickened skin), and itching. Venous ulcers generate a large amount of exudate and are usually surrounded by erythema and edema. Arterial insufficiency would produce shiny, taut, hairless skin. There is no indication the patient is a diabetic. There is no indication the patient has risks for pressure ulcers.
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