Sandra Seddon, RN, CNN, Staff Nurse, Fresenius Clinic Outpatient, Maplewood, NJ
My story involves a patient under my care this year for dialysis. The patient is diabetic and has a below-knee amputation of the left leg. He is a candidate for monthly checks on his right foot. Should there be complications on his foot, the outcome could have been disastrous, resulting in a bone infection, amputation, sepsis, or death.
Clearly the patient already is missing one limb and is not seeing the relationship of a wound on his foot to another amputation. He is possibly in denial and has refused foot checks repeatedly for months. He was still wearing a shoe and he did not want it removed for a foot inspection. The continued refusal is the patient’s right but it was my duty to educate him that he needed to be checking his own foot, as well as his stump. His lack of knowledge or denial could have a serious impact on his medical outcome.
Intervention become extremely important when the patient entered the clinic and took his shoe off, showing a blood spot on his sock. At this time the patient permitted inspection. The area was 3 cm by 3 cm, was an uneven round shape, was not infected. The tissue was bleeding, however there was no unhealthy tissue or odor at this time. The wound most likely was the result of a poorly fitting shoe and his lack of pain is related to his diabetes.
I knew the patient’s outcome depended on rapid medical care. To implement the plan of care, the patient was educated on the importance of immediate assessment and treatment. A nephrologist was notified, contact numbers were written down and given to the patient for podiatry and wound care centers. At each subsequent dialysis session, the patient’s compliance and realization of the seriousness of the situation was evaluated. Fortunately, the patient was now allowing his foot to be inspected during each dialysis visit, however the wound has worsened and was beginning to develop odor and black eschar.
My Own Learning
As a nurse, it is imperative to recall past experiences with small wounds on diabetic patients leading to loss of life and limb. This situation changed my nursing practice in the aspect of patients’ need to be educated repeatedly to allow foot inspections. Although a patient has the right to refuse, education needs to continue to explain the seriousness of foot problems, especially in the diabetic population.
To provide exceptional care, I knew I had to be persistent in my efforts to educate this patient. On an ongoing basis, I emphasized the importance of regular visits to a podiatrist or wound care center. During his dialysis sessions, I would inspect, clean, and dress the wound, while continuing to educate him on the seriousness of obtaining a wound care appointment.
By providing continuing education, referrals, and phone numbers for podiatry and wound care centers, I was empowering the patient to take hold of his situation. These actions, as well as monitoring his wound, allowed me to uphold my commitment to the highest quality patient care. I knew if an amputation could be delayed or avoided, we would succeed together.
Short term results indicated that the patient did obtain medical care, as he was hospitalized for his foot wound. Long term, hopefully, the wound was debrided in time to avoid amputation or infection.
In the process of evaluating my intervention, I realized it had a positive impact on the outcome: the patient received medical care at a hospital. This case reinforces that regular foot checks are extremely valuable in maintaining positive outcomes, and that communication and patient education are imperative when offering foot checks.
I think my certification benefited this situation and my practice overall, as well as my years of experience in the nursing profession. Certification requires work experience as well as CEUs that contribute to both learning and experience.
In the future, I plan to encourage “an extra pair of eyes,” as it can save life and limb. Educating a patient that a small irritation can quickly become an ulcer can be lifesaving.
The patient had a private caregiver with whom I collaborated and who served as a role model to expedite medical care. This advocacy by the caregiver was crucial because the patient also had a sore forming on his stump due to irritation from his protheses.
A Grateful Patient
In summary, the events that led to the hospitalization have been shared with the dialysis center staff. The patient called the unit recently to express his thanks for my concern for his wellbeing.
This case taught me the importance of being extremely vigilant with foot checks and helped me refine my patient education and communication skills.
While it’s important to respect patients’ right to refuse, it is critical to communicate that proper care could help them avoid serious consequences and hopefully put them on a path to healing.