Wound classification?

[Kim, HHRN]

Taking care of a man who has had weeping BLE distally from knees to toes and covers almost the entire leg surface, area red, edematous 3+, hard, endurated,bronze brown, looks like skin peeling around what perimeter remains. Is this classified as a venous stasis ulcer? There does not "appear" to be skin breakdown because you can not see any line of demarcation. Trying to do an OASIS assessment for HHA. Did not know if this technically classifies as a wound since there is not observable ulcer but we are having to tx with wound care. Any advice would much be appreciated!

[sorlando]

This could be a venous stasis ulcer, your description of bronze brown color sounds like some venous insufficiency. If you have weeping there has to be some openings in the skin so I would call it a wound.

[NursSherri]

First, I would make sure that this is not cellulitis. Red and indurated are classic signs here. This may be from prolonged LE edema r/t CHF. There does not have to be a "wound" for there to be weeping, but this may cause further skin instability and cause open wounds to occur. Look at his medical issues....liver failure? look at protein stores. Is this third spacing from a recent medical exacerbation? would he benefit from LE compression wraps?

[LadyT618, MSN, APRN, NP]

More information regarding health history would be needed to really hone in on the etiology of this wound. Could be venous insufficiency, could be prolonged CHF exacerbation and/or cellulitis due to due breakdown in skin integrity due to prolonged edema and poor treatment thus far.