There are four (4) common types of skin ulcers: venous stasis ulcers, arterial ulcers, diabetic neuropathic ulcers and pressure ulcers.
Three (3) of these ulcer types are exclusively lower-extremity wounds located on the foot, ankle and lower leg: venous stasis ulcers, arterial ulcers, and diabetic neuropathic ulcers. Venous stasis ulcers, caused by venous insufficiency, account for approximately 75% of lower extremity ulcerations.
OASIS Items M1330, M1332 and M1334 are focused solely on the incidence of venous stasis ulcers (VSU).
VSUs are prevalent among patients with
- history of edema in the legs
- history of long-standing varicose veins
- history of blood clots in either the superficial or the deep veins of the legs.
VSUs are located on the lower leg, medial malleolus, and superior to the medial malleolus. These are rarely on the foot or above the knee. VSUs have irregular wound margins and are typically shallow and ruddy red, and tend to have moderate to large drainage amounts. Although not typically painful, patients may complain of “achy” legs. Surrounding skin is scaly and weepy, possibly with discoloration and edema. The patient usually has palpable pulses. See below for Assessment Guidance for OASIS Item M1330 Stasis Ulcers.
Arterial ulcers, also known as ischemic ulcers, are caused by reduced circulation of the lower extremities. In ischemic diseases, skin and tissues are deprived of oxygen, killing tissue and sometimes causing an open wound. In addition, a reduced blood supply can result in minor scrapes or cuts which fail to heal, eventually developing into ulcers.
Arterial ulcers are often found between or on the tips of the toes, on the heels, on the outer ankle, or where there is pressure from walking or footwear. Arterial ulcers are characterized by a punched-out look, usually round in shape, with well-defined, even wound margins. The wound is typically deep, frequently extending down to the underlying tendons.
Vascular and neuropathic complications of diabetes cause a diabetic foot ulcer. Nerve damage due to diabetes causes altered or complete loss of feeling in the foot and leg. This is known as peripheral neuropathy. Pressure from shoes, cuts, bruises, or any injury to the foot may go unnoticed.
Diabetic foot ulcers occur on the bottom of the foot, over metatarsal heads where, and under the heel. They have even wound margins and often are deep ulcers with red or pale granular wound beds.
A pressure ulcer (also known as bedsore, pressure sore, or decubitus ulcer), by contrast, is an area of damaged skin and tissue caused by sustained pressure to certain areas of the body. The areas of the body most vulnerable to pressure sores are the heels, hips, and buttocks.
Assessment Guidance for OASIS Item M1330 - from the OASIS Guidance Manual
• Determine status of the most problematic stasis ulcer that is observable using healing status definitions developed by the Wound Ostomy and Continence Nurses (WOCN) Society:
• Response 1 – Fully Granulating: Enter Response 1 when a stasis ulcer has a wound bed filled with granulation tissue to the level of the surrounding skin or new epithelium; no dead space, no avascular tissue; no signs or symptoms of infection; wound edges are open.
• Response 2 – Early/Partial Granulation: Enter Response 2 when ≥ 25% of the wound bed is covered with granulation tissue; there is minimal avascular tissue (that is, <25% of the wound bed is covered with avascular tissue); may have dead space; no signs or symptoms of infection; wound edges open.
• Response 3 – Not Healing: Enter Response 3 when wound has ≥25% avascular tissue OR signs/symptoms of infection OR clean but non-granulating wound bed OR closed/hyperkeratotic wound edges OR persistent failure to improve despite appropriate comprehensive wound management.
Once a stasis ulcer has completely epithelialized and is without signs/symptoms of infection, it is considered healed and should not be reported as a current stasis ulcer.
- Wound Care Advisor. (2020, February 25). How are you differentiating the "big three"? Retrieved September 24, 2020, from https://woundcareadvisor.com/how-are-you-differentiating-the-big-three/
- Lazarus, G., & Jourabchi, N. (2019, March 13). Ulcers, Leg (venous stasis ulcers, arterial ulcers, diabetic neuropathic ulcers, pressure ulcers). Retrieved September 24, 2020, from https://www.dermatologyadvisor.com/home/decision-support-in-medicine/dermatology/ulcers-leg-venous-stasis-ulcers-arterial-ulcers-diabetic-neuropathic-ulcers-pressure-ulcers/
- Yvette C. Terrie, B. (2017, February 16). Recognizing and Treating Venous Stasis Ulcers. Retrieved September 24, 2020, from https://www.uspharmacist.com/article/recognizing-and-treating-venous-stasis-ulcers
OASIS User Manuals. (n.d.). Retrieved September 24, 2020, from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIOASISUserManual