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Debriding diabetic foot ulcers

Discussion in 'Diabetic Foot & Wound Management' started by sparkyclair, Mar 28, 2013.

  1. sparkyclair

    sparkyclair Active Member


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    Hi all

    I just want some reassurance that I am doing things right! I attended, by request, a lady at a care home. I am a private practitioner and generally don't get involved in wound care, however I knew the lady some years ago when she was living at home.

    She has DM II and has had several toes amputated since I knew her. She has an ulcer on her foot about 5 x 2 cm which was heavily calluses. I checked with the nurse matron who told me that a tissue viability nurse recommended to leave the ulcer alone callus and all.

    I felt this to be wrong, and said that the NICE guidelines suggest sharp debridement along with other therapies to ensure wound healing. Am I right on this? The CG10 guidelines do not appear to have changed, and a 2013 cochrane review recommends sharp debridement as being necessary for wound healing.

    I just wondered why a tissue viability nurse woud recommend leaving the callus intact?

    Any thoughts?

    Many thanks

    Clair
     
  2. blumley

    blumley Active Member

    I have also come across this whilst on placement last during 2nd year, the patient had been having regular debridement with other therapies. The consultant then decided that this was not correct and requested that the podiatrists no longer debrided this wound, despite raising their concerns the patient went with what the consultant had recommended.

    This wound just got worse and worse and in the end the consultant then requested debridement of the wound. I wonder why people are advocating no debridement is there some conflicting evidence for it?

    Now I am still a student so experience in this area is limited, but from what I have read wounds like this need sharp debridement?

    kind regards

    Ben
     
  3. alaranjo

    alaranjo Member

    Hi,

    To explain in few words, for a perfect wound healing, there must be viable tissue. Tissue viability analysis is essential, and then, sharp debridement. If you don't perform sharp debridement in a callus, the wound is suitable to an infection and further on, amputation. Just remember the Meggit-Wagner Classification. Check this image:
    https://www.facebook.com/photo.php?...35704252254.92402.127081827254&type=1&theater
    Before the amputations, I'm 99.9% sure, she had an infection caused by straight shoes or hiperpression points, that caused callus which weren't debrided and the toes had to be amputated. Debridement is fundamental in a diabetic foot callus, and then treat the ulcer, with proper dressings and/or offloading footwear/orthotics.
     
  4. alaranjo

    alaranjo Member

    Exactly what I mention! Debridement is essential and of course footwear therapy and orthotics!
     
  5. sparkyclair

    sparkyclair Active Member

    Hi Ben

    Thanks for your comment. I know there is some issue with debriding ischaemic ulcers but I am pretty sure that debridement is still needed even before revascularisation if this is necessary. My lady has a neuropathic ulcer. I sharp debrided and dressed but will get in touch with her gp and podiatrist linked to the surgery for their input. This is weighing heavy on my mind!!
     
  6. sparkyclair

    sparkyclair Active Member

    Thanks Andre. There seems to be in issue in the care home setting, in that things such as offloading aren't incorporated as part of the care pathway, I guess because they are too busy. Frustrating and unfair for the resident.
     
  7. Simon Ross

    Simon Ross Active Member

    To Quote podistrist Neil Baker who gives talks at conferences:

    "if you see callous, then that needs debridement (to not debride is negligence)

    if not debrided, that callous can go to ulcerate, and possibly amputation."

    lovely way to get sued.

    but cover your backisde and write EVERYTHING in the notes, including who said what.
     
  8. blumley

    blumley Active Member

    Hi sparkyclair,

    By sounds of it what you have done sounds reasonable. If you have thoroughly documented everything and contacted gp then I am not sure what else you could have done? Perhaps speaking to the nurse in question may be of benefit at least that way you will be able to understand her rationale? maybe the matron in question is mistaken?

    I am sure there are more qualified practitioners kicking around who are able to give better advice, but thought I would offer my opinion.

    Kind regards

    Ben
     
  9. alaranjo

    alaranjo Member

    Yes, forgot that. Always write everything!
     
  10. Tom Quinton

    Tom Quinton Member

  11. David Smith

    David Smith Well-Known Member

    Here's a simple guide attached

    Dave
     

    Attached Files:

  12. dazzalyn1

    dazzalyn1 Member

    Hi Sparkyclair,
    I'm also a private pod who treats a lot of doms and occasionally comes across patients with diabetic ulcers which haven't been looked at by NHS podiatry services. I debrided/clean/cover/offload using felt and also do it in the presence of the senior nurse on duty if it's in a care home because in that way you can educate the care giver at the same time(even though they won't redress the ulcer). I then telephone the GP and request an urgent referral to NHS pods. I also telephone and speak to the community nurses who are usually familiar with the patient and leave a redressing pack for the community nurses with padding cut to shape as they will often be the first to see the patient before the NHS pods. I write in detail to the GP and obviously record everything.
    Tissue viability nurses are not podiatrists, they see all sorts of wounds e.g bed sores, non-healing lesions on any part of the body.
    I have found it invaluable to build up good relationships and referral pathways as and follow up on all referrals. That way I can sleep at night and know the patient is in the hands of a multidisciplinary team.
    Kind regards
    Lynda
     
  13. dazzalyn1

    dazzalyn1 Member

    p.s. Sparkyclair,
    I hope I didn't sound disrespectful to tissue viability nurses in my previous post. They are expert in their field, I've seen sloughy wounds heal quickly when they have prescribed prontosan for example (non-mechanical debridement) and have an indepth knowledge of dressing types.
     
  14. nammoura

    nammoura Welcome New Poster

    Depridment of the foot callus is the most esential step of diabetic foot managment, it will minimise the risk of infection and facilitate the healing process. . using the Contrast bath by emersion of the Legs in a dequate hot water in a plastic container for one minute and in cold water on another one for Half a minute. for ten times in each continuasly once daily followed by adequate dressing and of lowding, will increse the healing proces and decrease the healing time.
     
  15. sparkyclair

    sparkyclair Active Member

    Thanks everyone for your really helpful responses, I have been able to establish a good rapport with the matron and so far fingers crossed all is going well!!
     
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