1. Hess, Cathy Thomas BSN, RN, CWOCN

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Mrs R, 74, has a primary diagnoses of type 2 diabetes, peripheral vascular disease, and a full-thickness wound to the dorsal/lateral aspect of her right foot (Figure 1). The wound had developed from an improperly fitted shoe. Mrs R sought treatment and was admitted to the hospital when the wound began to exude purulent drainage. She had also developed a low-grade fever and her blood glucose level exceeded 250 mg/dL.

Figure 1 - Click to enlarge in new windowFigure 1. FULL-THICKNESS WOUND ON DORSAL/LATERAL ASPECT OF RIGHT FOOT

During the physical examination, the physician found it difficult to obtain a pedal pulse in Mrs R's right foot and ordered vascular testing. The tests revealed a decrease in blood flow to the right foot. Coupled with the improperly fitted shoe, the reduced blood flow played a significant role in wound development.


Mrs R underwent a right femoropopliteal bypass procedure to increase blood flow to her leg and foot. Moist saline dressings were applied twice daily to the wound. In addition, she was treated with intravenous antibiotics and her blood glucose was brought under tight control. The physician then discharged Mrs R to a subacute care facility for rehabilitation and wound management.



The admitting nurse at the subacute care facility takes a detailed history and performs a physical examination, including skin and wound assessments. The gauze dressing applied at the hospital is difficult to remove from the wound base, and the admitting nurse recommends that it be switched to a dressing that would increase wound hydration.


Mrs R's foot wound is still full-thickness with an exposed tendon. The wound appears dehydrated, with only a scant amount of serous drainage. The wound base is 85% slough and 15% granulation tissue. The wound margins are fused and appear intact; tunneling is not seen.


The periwound skin is warm to the touch. Mrs R reports that the wound is not painful and that she has complete sensation in the foot following the revascularization procedure. After the wound assessment, a complete body assessment is performed and no significant concerns are found.


Following the physician's evaluation of Mrs R, a comprehensive care plan should be developed that follows the subacute care facility's policies and procedures for skin and wound care.



Interventions should focus on caring for the foot wound and surgical site, preventing further skin breakdown, and keeping Mrs R's blood glucose level under control.


Assessment of Mrs Rindicates that she is not at risk for pressure ulcer development. Because her mobility is compromised following surgery, however, she should be provided with a pressure-reducing chair cushion and mattress system. She should be encouraged to participate in physical therapy and group activities. In addition, she should avoid sitting or standing in one position for more than 2 hours. She should be encouraged to walk, which will improve blood flow to and from the feet and legs.


Because Mrs R has diabetes, a nutritionist should be consulted and fasting blood glucose checks should be performed each morning. Mrs R takes oral hypoglycemic agents for blood glucose control, but may need insulin if her blood glucose level begins to rise.


Mrs R's foot wound and the exposed tendon are dry, therefore, a dressing that hydrates the wound-such as a hydrogel-should be used. This will allow granulation tissue to form over the tendon. In addition, the physiatry staff should be consulted about developing a customized off-loading orthotic device for Mrs R's right foot. The device will help with healing by removing pressure from the wound area.


Mrs R should be taught about wound care and how to manage her diabetes. Good documentation should be maintained, which will help with home health care when Mrs R is discharged.