Terrible infection in pts foot

1. I have a 46 yo gentlemen on my floor right now who is diabetic. He had a pedicure about 2 weeks ago. He came into the ED about 2 weeks ago and was placed on antibiotics and then followed up with the wound clinic. They admitted him to my floor because his wound was so bad.
   
   Yesterday I took a look at his foot as his primary nurse was doing his dressing change. He has a large triangle of flesh gone from the top of his foot and you can see the tendons. All the areas around the wound are blanched white as are his toes. It appears that this skin is not attached to anything. Some blanching to the bottom of his foot. The surgeon did a debrib earlier the week and he is going to need another. He has ESBL. He is going to need a skin graft to close.
   
   I am just very worried about him. I have a feeling that he is going to lose his foot. I need some feedback from some wound care nurses or OR nurses. What do you think his chances are?

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2. 9 Comments

   Topic Closed
3. 
   Apr 24, '09

   ok, I have absolutely no advice for you...but I just wanted to say you sould like a GREAT nurse. Your patient is lucky to have you.
   I hope someone gives you some good advice.
4. 
   Apr 24, '09

   I wouldn't dare advise thru this medium, but wonder if your facility has a wound care nurse? skin care committee? Even recommending a dermatologist consult might be good.
5. 
   Apr 24, '09

   I would think the patient needs an Infectious Disease Specialist in addition to the Wound care doctor.
   
   Diabetic patient's can and do heal, it just takes longer as you already know. Meanwhile it would not hurt to ask it he sees a podiatrist for his foot care as god knows he should not just be having his toe nails cut just anywhere.
6. 
   Apr 24, '09

   I've seen some wonderful results with the wound vac.After they get a handle on the infection they can attempt something like that.
7. 
   Apr 24, '09

   In my experience I have seen patients with similar wounds and situations that you are describing heal and I have seen others who have not. This persons chances of healing depend on the control of his diabetes, his nutrition, the level of his infection, ect. I would suggest that they consider using hyperbaric oxygen therapy. It makes a huge difference in the healing process. It will help eliminate anaerobic infections, helps increase angiogenisis, accelerates and enhances osteoclast and osteoblast activity, increases blood flow because it hyperoxygenates the plasma which can get oxygen around diseased blood vessels(which most diabetics have), ect. The use of Hyperbarics, a wound vac, IV antibiotics, ect will give this person the absolute best opportunity for healing. Using these things I have seen people with wounds similar to this heal without skin grafts. I hope this helps!
8. 
   Apr 24, '09

   It's hard telling from a post on the internet.
   
   My main advice to you would be to keep his sugars under control and high quality diet. Diabetes education if the patient is receptive.
   
   You sound like a very caring nurse.
9. 
   Apr 25, '09

   I have also seen extraordinary results from VAC drsgs. It's worth the suggestion! Please request a consult from a Wound Care Nurse/Specialist if available.
10. 
    Apr 25, '09

    I've seen wonderful things from Mist Therapy....looks like a little spray gun with ultrasonic? ultra-something mist coming from it.
    
    The only wound I've gagged from was a stage IV (bone and all) going from the top THROUGH the foot to the bottom. Pus oozing, lovely smell.
    
    It took 2 months, but daily mist therapy healed it!
11. 
    Apr 25, '09

    He is being followed by an ID doc (who is really good) and the Wound Care Department. They placed a wound vac and the wound nurse agreed with me that is appears that he has areas of skin detachment around the wound. He is going to have a minimum of a skin graft and my still lose his foot. They may start hyperbaric therapy soon.

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