Case Study

You are a 2-year seasoned nurse working on a busy internal medicine unit where you often see patients admitted for diabetic patients’ ulcers. During your bedside shift report today, the night nurse tells you to allot ample time to complete the dressing for one of your patient’s unstageable diabetic ulcers on eir left heel, and that plastic surgery was still pending their consultation. Given it was a Sunday, they were not likely to consult until the following day on Monday.

You planned your day accordingly and allotted 20 minutes for the dressing change. After checking the wound care dressing orders and checking the supplies at the bedside you are prepared for the dressing. You began to remove the old dressing and begin conversing with the patient about eir diabetes and wound management at home.

You noted that the patient’s wound is 10 cm long, 5 cm deep and 7 cm wide, with sloughing, necrotic tissue, and lots of granulated tissue on the wound bed and peri-wound. The patient’s bone is visible, however, due to the diabetic neuropathy, the patient doesn’t report any pain. The wound care NP had ordered to clean with betadine and pack with wet-to-dry dressings. Based on your assessment you plan to pack the wound with betadine-soaked ribbon for the tunnellingand undermining. You think to yourself, that this patient really needed to be seen by plastics and noted that you should call the on-call plastics doctors to see if they could consult sooner.

You ask, “Houriya, how long have you had this wound and how have you been managing it at home?”

Houriya responds “Oh, I have had this for a few months, and I have a nurse who comes 3 times a week, but it doesn’t bother me. I used to have an ulcer-like this on my right toe 2 years ago and look at it now, it’s all healed”

You look at the right toe and it has completely healed with only a thick keloid scar noted about 5 cm long. You respond, “What type of treatment did you receive for your toe?”

Houriya: “Oh, my sister lives in Sri Lanka and I sent her a picture of my toe, which she showed to a naturopath and he gave me this topical cream to apply 2 times a day. After a few weeks, it was all healed. This is why I don’t think I need to see the surgeons here who are going to say I need to cut off my foot. Can you take a picture of my foot now, so I can send it to my sister, and she is going to show it to the doctor in Sri Lanka again?

You are a bit taken aback by Houriya’s comment, as you can see that the wound has progressed and you do not understand how a topical cream can heal this wound and the underlying issue of diabetic neuropathy.