The nurse notes an oozing, shallow, irregularly shaped ulcer on a client's lower leg. The surrounding tissue is bruise-like in appearance. The nurse correctly documents this as:
Explanation & Rationale
A. Deep tissue injury: Deep tissue injuries typically present as a localized area of intact or non-intact skin with persistent deep red, maroon, or purple discoloration due to underlying soft tissue damage. They are not usually described as shallow, oozing ulcers with irregular borders, which differentiates them from the findings here. B. Stage 2 pressure ulcer: Stage 2 pressure injuries involve partial-thickness skin loss with exposed dermis and appear as shallow, open ulcers or blisters. They are usually associated with pressure over bony prominences and do not typically present with irregular borders and chronic oozing on the lower leg, nor with surrounding discoloration related to venous insufficiency. C. Arterial ulcer: Arterial ulcers are typically located on distal areas such as the toes or lateral ankle and present with well-defined, “punched-out” edges. The wound bed is often pale or necrotic with minimal drainage due to poor blood supply, which contrasts with the oozing, irregular ulcer described. D. Venous ulcer: Venous ulcers are commonly found on the lower leg and are characterized by shallow depth, irregular borders, and moderate to heavy exudate (oozing). The surrounding tissue often appears discolored or bruise-like due to hemosiderin deposition from chronic venous insufficiency, aligning with the findings.