A case study of a patient with a diabetic foot ulcer (DFU) with management from the Multi disciplinary team (MDT) for wound care and limited access to pressure relief

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Abstract[edit | edit source]

The purpose of this case presentation is to highlight the limited of pressure relief in a patient with a diabetic foot ulcer (DFU) due to a lack of resources. A female, 49 years old, diabetic, active, with inappropriate footwear attends the local community clinic for regular visits over the course of two months. The intervention plan includes input from the Multi disciplinary team which includes nurses, doctors, pharmacist, radiographers and podiatrists. The wound care is provided once every alternative week. The patient is responsible for her own wound care, between visits, during this period. The research shows that neuropathic diabetic foot ulcers on the plantar surface heal well with the correct offloading in place, such as insole/orthoses devices and the appropriate footwear[1]. The issue highlighted, however, in disadvantaged communities, is that the patients cannot afford this type of pressure relief. Patients often cannot afford correct footwear and resort to wearing plastic thong type sandals with thin soles, which cause friction and shear pressure inter digitally.


Introduction[edit | edit source]

The patient attends the local government run community clinic in a disadvantaged area. There are limited resources and the government health department must allocate resources equally to those who are vulnerable with healthcare needs at the local point of the clinic. A 49 -year old female, medical history diabetic and smokes attends the clinic for wound care for the plantar diabetic foot ulcer under the first metatarsal on the right foot. The patient has no transport and walks to the clinic and to work. The footwear is inappropriate, slip on sandals are afforded on the tight budget, that must also be allocated to care for her family. Studies show that foot orthoses to offload the plantar ulcer and the correct footwear would help to heal the wound[3]. As footwear orthoses and footwear were not available, This study discusses the alternative plan that was advised to help promote healing and relieve pressure away from the wound (DFU).

Examination Findings[edit | edit source]

The examination findings were taken for the patient in the community clinic. Past medical history was taken.  Among the results from the tests, a glucose test showed that the glucose was controlled. A vascular foot test showed that the pedal pulses were palpable. A test of light touch protective sensation detected that there was slight neuropathy in the plantar surface under metatarsals one to five[1]. The dorsiflexion passive non weight bearing test result was that there was limited dorsiflexion of the ankle joint less that ten degrees. The X-ray showed no signs of osteomyelitis[1]. The patient experienced distress, anxious for the wound to heal, so that she could return to work and look after her family and grandchildren at home. 

Clinical Hypothesis[edit | edit source]

The assessment found that the patient had a diabetic foot ulcer, the wound bed was purulent, with erythema and swelling the peri-wound skin was red, with callus and the wound edges were thickened. The wound was increasing in `size by a centimetre over the last four weeks and non healing[4]. In terms of wound classification this was a high risk, active ulcer[1]. On the fourth week, signs of charcot neuropathy was suspected.  Limited ankle dorsiflexion showed ankle equinus. An X -ray did not show signs of osteomyelitis. An ultrasound and an MRI were not available at the clinic due to the costs. The MDT management plan involved a total contact cast (TCC) to relieve pressure from the area of the DFU[1].

Intervention[edit | edit source]

This was classified as a high risk active foot ulcer with moderate foot infection[1]. The management options would ideally follow the steps of the protocols[1]. The internal factors for the foot ulcer included neuropathy and inappropriate footwear. External factors included poor access to healthcare[5]. However, in a disadvantaged community in a third world country, the usual offloading devices such as foot orthoses and the appropriate footwear, or crutches were not within the resources of the clinic or the patient’s budget. The management goal was to offload the DFU with a pressure relieving device and manage the local wound infection[4].  It was advised that a total contact cast would be advisable to offload the DFU at the next visit. Until the next visit to the clinic, the patient was asked to stay off her feet as much as possible. The patient agreed with the plan and to remain at home with her feet up and not to walk around in the house. The results of the wound swab showed infection.  The Doctor prescribed first choice antibiotics to the patient to help with the infection in the foot wound. The podiatrist cleansed and debrided the wound area with saline and used a wound dressing to protect the area. Advice for caring for the wound was given for self-care measures until the next visit[4].

Outcome[edit | edit source]

At the follow up visit the wound size was smaller in size and depth and the infection had cleared. The goal of healing was important to the patient and clinicians. The patient had followed the advice to stay off the foot with the DFU as far as was possible.  A total contact cast (TCC) was applied to help progress the healing of the wound[3].

Discussion[edit | edit source]

It was recognised that the issue was that a female from a disadvantaged community, working age parent was involved. The problem was that patient was suffering from a diabetic foot ulcer that was deteriorating, there was no pressure relief due to the incorrect footwear and no insoles. This occurred in the local community clinic over the period of two months[6]. The ethical concern includes distributive justice, as the Health Department must allocate resources for the greater good, for wound cleansers, dressings and vaccinations for the community[7]. The facts were that there were very limited resources to provide for offloading devices such as off the shelf orthoses to relieve pressure away from the foot ulcer. The custom made orthoses were only available at a different clinic in a remote place with a long waiting list.  There was no access to expensive diagnostic techniques such as MRI, CT scans to rule out differential diagnosis or detect charcot arthropathy.  As part of the team, I was unsure how the MDT could help the patient and work together to heal the wound. It was recognised that there was an issue of non-maleficence. That is, do no harm to others[8]. The resources were provided for the health needs of the community, in that resources are provided for those with the greatest needs.  More of the population would benefit from healthcare items for the care that the health team. This included what the health professionals felt they were responsible for, and what was owed to the community and the patient to help prevent infection such as wound dressings and wound cleansing solutions and the correct protective equipment; such as disposable gloves and aprons.

The outcome was that the most affordable alternative was offered.  The option was for the benefit to the patient. Although there was limited resources, the patient found alternative means to relieve pressure off the area while at home for the week. The patient avoided walking on the affected foot, used second hand crutches that were lent to her in the community, to assist with walking. This was implemented as well as the correct wound care and medication. As a result of this, at the next visit, the wound measurements showed that margin size and depth had diminished and there were no signs of infection. The reason why the offloading advice was given, was to prevent any further delays in healing. At the next follow up appointment, the total contact cast was applied. In this way the care was balanced to help the patient. The Doctors and podiatrists and nurses worked together with the patient and there was a sense of partnership, to help towards the goal of healing the wound. In terms of ethics the podiatrist and doctor were autonomous and accepted responsibility. This was done as they assessed the patient and involved the patient in the care of the wound. There was an overall principle of fairness as the patient worked in partnership and adhered to the advice given to self care for the wound at home. The most expensive offloading treatments were not available at this setting. However, on reflection it was noted that the team (MDT) worked together with the best options towards the goal of healing of the wound[9].  In this way there was an arrangement so that although there were economic inequalities, there was benefit maximisation for those who were least advantaged.  The team worked in partnership with the patient, despite a lack of resources, to ensure that the care was implemented effectively the well being of the patient was regarded by the health care practitioners[10].

Literature Search[edit | edit source]

Online; Semantic scholar; Offload and diabetic foot ulcer; Wound and foot; Ethic principles

Google scholar; Offload and diabetic foot ulcer

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 National Institute of Clinical Excellence (2019) Diabetic foot problems: prevention and management [online] nice.org.uk/guidance NG19
  2. Michigan Medicine. Diabetic Foot Ulcer 101. Available from: http://www.youtube.com/watch?v=IQy6E5aVUzo [last accessed 28/01/2023]
  3. 3.0 3.1 Armstrong, D, G. and Mills, J, L. (2013) Toward a change in syntax in Diabetic Foot Care prevention equals remission Journal of the American Podiatric Medical Association 103 (2) 161-2.
  4. 4.0 4.1 4.2 Dowsett, C; Protz, K; Drouard, M; Harding K, G. (2015) Triangle of Wound assessment made easy, Wounds Asia [online] woundsasia.com.
  5. Bus, S., Lavery, L, Monteiro-Soares, M, Raspovic, A.  (2019) Guidelines on the prevention of diabetic foot ulcers in persons with diabetes, IWGDF guidelines, Wiley 10.1002dmrr32699
  6. Davidson P, Rushton CH, Kurtz M, Wise B, Jackson D, Beaman A et al. (2018) A social-ecological framework: A model for addressing ethical practice in nursing. J Clin Nurs. 2018;27(5-6):e1233-e1241.
  7. Page K. (2012) The four principles: Can they be measured and do they predict ethical decision making?   BMC medical ethics. 2012 Dec 13(1):10
  8. Pera, S. and Van Tonder, S. (2018) Ethics in healthcare, 4th edn, Juta.
  9. Human, S. and Mogotlane, S. (2017) ‘Professional Practice: a SA Nursing Perspective,’ 6th edn, Pearson.
  10. Nursing midwifery council (NMC) (2022) The code: professional standards of practice and behaviour for nurses [online]www.nmc.org.uk Portland place