If the wound is on the plantar surface, off-loading the foot is essential for healing. Keeping the patient non-ambulating with crutches (OK, I realize she's 83...) or a wheelchair. Otherwise, if the wound is on the side of the foot, can pressure relief be improved with a padded ankle-foot orthosis, (multi-podus boot)?
Have you established the patient's healing potential? How's her nutrition, weight stability, albumin, pre-albumin? Control of blood sugars, HgbA1c? Control of other co-morbidities, hypertension, CHF?
Have non-invasive vascular studies been performed? The presence of distal pulses (dorsalis pedis or post. tibialis) in the diabetic foot aren't necessarily sufficient evidence of adequate in-flow. In the individual with diabetes, an ankle-brachial index may be falsely reassuring. Often results can display ratios greater than 1.0 indicating the pressure in the foot is higher than the arm, likely due to non-compressable calcified distal vessels. Plethysmography or toe pressures can be very helpful in assessing arterial flow in the diabetic foot.
I actually like Panafil
. Lately, I've been using it more than Accuzyme or Santyl.
Remember, there is significant evidence that suggests regular agressive surgical debridement reduces the healing time of chronic wounds. Are you able to have the patient seen by a podiatrist or other surgical specialist with competency in advanced wound management?
Rand Feinstein, RN, PA-C, CWCN