Special Considerations in Wound Care
Special Considerations in Wound Care ( 3 Questions)
A client with arterial insufficiency has an arterial ulcer on the dorsum of the foot. Which assessment finding should alert the nurse to a potential complication?
This is an expected finding in clients with arterial insufficiency, as the blood flow to the lower extremities is compromised. The nurse should document this finding and compare it with the baseline and previous assessments.
This is an expected finding in clients with arterial insufficiency, as the skin does not receive adequate oxygen and nutrients from the blood. The nurse should document this finding and monitor for changes in skin temperature and color.
This is an expected finding in clients with arterial insufficiency, as the hair follicles do not receive adequate oxygen and nutrients from the blood. The nurse should document this finding and educate the client about proper foot care.
Rationale: The client with arterial insufficiency has reduced arterial blood supply to the lower extremities, which causes ischemia, pain, and tissue damage. Gangrene or necrosis of the toes indicates severe tissue death that can lead to amputation if not treated promptly. The nurse should report this finding to the provider immediately and monitor for signs of infection or sepsis.
Correct answer: D) Gangrene or necrosis of the toes.
Rationale: The client with arterial insufficiency has reduced arterial blood supply to
the lower extremities, which causes ischemia, pain, and tissue damage. Gangrene or necrosis of
the toes indicates severe tissue death that can lead to amputation if not treated promptly. The nurse should report this finding to the provider immediately and monitor for signs of infection or sepsis.
Incorrect options:
A) Absent or diminished pedal pulses. - This is an expected finding in clients with arterial insufficiency, as the blood flow to the lower extremities is compromised. The nurse should document this finding and compare it with the baseline and previous assessments.
B) Cold, pale, or cyanotic skin color. - This is an expected finding in clients with arterial insufficiency, as the skin does not receive adequate oxygen and nutrients from the blood. The nurse should document this finding and monitor for changes in skin temperature and color.
C) Loss of hair growth on the lower leg. - This is an expected finding in clients with arterial insufficiency, as the hair follicles do not receive adequate oxygen and nutrients from the blood. The nurse should document this finding and educate the client about proper foot care.