Wound Care

112 Nurse to Nurse
formation due to the relative lack of oxygen and nutrient
flow to the area. 12
— Capillaroscopic studies have shown dense loops of
glomerulus-like capillaries with microvascular obstructions.
• These ulcers often develop slowly and can exist for years.
PHYSICAL ASSESSMENT OF THE
EXTREMITY
Assessment of the lower extremity includes evaluating the presence
or absence of pulses (Table 4–1) and the absence or presence
of edema (Figure 4–3).
• To assess pitting edema, press your index finger over the
bony prominence of the tibia or medial malleolus for several
seconds. A depression that does not rapidly refill and resume
its original contour indicates orthostatic (pitting) edema,
which is not usually accompanied by thickening or pigmentation
of the overlying skin.
— 1+: slight pitting; no visible distortion; disappears rapidly
— 2+: a somewhat deeper pit than in 1+, but again no readily
detectable distortion; disappears in 10 to 15 seconds
— 3+: the pit is noticeably deep; may last more than
1 minute; the dependent extremity looks fuller and
swollen
Table 4–1 Grading of Pulses
Pulses
0 Absent
1+ Barely palpable
2+ Palpable but diminished
3+ Normal
4+ Prominent, suggestive of an aneurysm
From: Hallett JW, et al. Manual of Patient Care in Vascular Surgery. Boston, MA:
Little, Brown & Co; 1982.