Table 12.10: Clinical Indicators of Common Lower Extremity Wounds (PAZ Textbook)

what are 11 clinical indications of ARTERIAL INSUFFICIENCY

1. intermittent claudication

2. extreme pain/cramping

- decreased with rest + dependent positioning

- increased with exercise + elevation

3. decreased/absent pedal pulses

4. delayed capillary refill

5. decreased temperature of distal LE

6. full-thickness wound depth with distinct well-defined wound edges

7. wounds located on anterolateral leg, distal foot + toes

8. pale granulation (if any)

9. presence of nonviable tissue (eschar)

10. minimal drainage

11. shiny, anhydrous, pale to cyanotic skin

what are 7 clinical indications of VENOUS INSUFFICIENCY

1. lower limb discomfort, heaviness + edema

- decreased with elevation + activity

- increased with rest + dependency

2. pedal pulses present (unless arterial disease also present)

3. irregularly shaped, shallow wound

4. located on medial lower leg + malleolus

5. fibrous slough covered wound bed

6. moderate to copious drainage

7. hemosiderin staining + lipodermatosclerotic changes

what are 7 clinical indications of DIABETIC FOOT ULCERS (neuropathic)

1. painless ulcers (lower limb neuropathic pain patterns may be present)

2. normal pedal pulse

- if arterial disease present = absent pedal pulse

3. decreased temperature secondary to arterial insufficiency or hyper-perfusion due to autonomic neuropathy component or in areas of repetitive trauma

4. full-thickness wound located at pressure points on foot + toes (plantar surface of foot, metatarsal heads)

5. wound surrounded by area of callous

6. pale wound bed with nonviable tissue + minimal drainage

7. trophic changes of skin, hair + nails due to autonomic neuropathy (dry, cracked, hairless, callous formation)

what are 5 clinical indications of PRESSURE INJURY

1. pain present if sensation intact

2. present over areas of pressure (bony prominences)

3. vary significantly in depth + appearance from superficial epidermal injury to full-thickness wound with exposed subcutaneous structures, undermining + tunneling

4. periwound maybe intact/normal in appearance or characterized by nonblanchable erythema/induration

5. pulses intact (unless vascular compromise is also present)