Mr. Robert B. is a 48 y.o. male who has been suffering with a Rt. plantar foot ulcer for nearly 6 (six) years. Initial H&P January 2009, revealed that this patient had been treated with multiple dressing types. He has had several home health nursing agencies over the years and was seen by a local wound care center in the last 6 months. They had treated with Regranex and Hyperbaric oxygen. He related no benefit from the recent treatments and stated he could not afford the $200.00/week co-pay required by the wound care center or his 20% of the cost of the > $600.00 tube of Regranex. He has been referred to a surgeon for grafting vs. amputation, yet relates inability to "put up the $700.00 they want upfront". He has turned to his primary physician for direction who has once again ordered home health nursing.
Upon initial visit by the WOC Nurse at the request of the agency, the pt. is found washing his wound in a bucket of isopropyl alcohol and hydrogen peroxide. He was applying ABD pads over his heavily exudating wound and wrapping with Kerlix. He has a makeshift sandal for his Rt. foot and ambulates with a cane & walker. He appears despondent relating he does not want to lose his leg. He is unable to leave his apartment without a strenuous and taxing effort.
Patient has type 2 insulin dependent diabetes with poor control (HgB A1C is 8.1), essential hypertension is well controlled with diuretics and antihypertensives (normaltensive) and hyperlipedemia is controlled by statins (triglycerides are mildly elevated, HDL & LDL are on the low side of normal). Physical exam reveals a morbidly obese male (BMI 48) with advanced Charcot feet who resides alone, in an unkempt apartment, is unable to walk greater than 25' at a time due to a moderately painful large draining full thickness neuropathic ulcer. He verbalized compliance with his medication regimen. He verbalizes knowledge deficits of diabetic management and the potential complications and effective wound care measures.
Pt. was assisted initially with social services to obtain authorization for an electric scooter to offload his Rt. foot and home making assistance, is provided instruction in basic would care without the use of cytotoxic agents, infection control measures and diabetes management. Moist wound healing principles are followed. Drainage management is second in importance after offloading. Home health nurses make home visits 3-4 times per week for wound care and instruction.
After offloading is achieved in February 2009 the wound begins to contract. Home health nursing continues trying to balance the moisture of his wound bed relating no drainage during some visits and heavy drainage during others. Diabetic management compliance is evidenced through bi-weekly FSBG levels. The patient was now able to exit his home for more frequent MD visits as his scooter allowed access to a handicapped public transport.
Home health staff relates that the wound stalled in April 2009. The WOC Nurse is asked to re-evaluate the patient the beginning of May. It is decided, with patient & his practitioner's consent, to begin a trial of hydrophilic polymer wound gel with free radical binding capabilities. The staff and pt. were educated in its use.
Another wound care specialist visit later in May confirmed patient and staff compliance plus a reduction in wound area and decrease in drainage. It was decided to apply the gel to adjacent skin as well as the wound bed due to a persistent dermatitis. The dressings were changed to a composite dressing with a non-stick wound contact layer and hypoallergenic tape border. The wound care visits were decreased to twice weekly.
A WOC Nurse visit the beginning of July revealed complete closure and re-epithelialization. There was a light callus border which the pt. admitted to "pulling off a piece". Surrounding skin was free of dermatitis. Patient final instructions included diabetic foot care, referral to a DPM for maintenance visits and literature from a local diabetic support group.
In conclusion, this patient with a six (six) year history of a complex Rt. plantar foot neuropathic ulcer, was able to achieve full closure in two (2) months after the introduction a hydrophilic polymer wound gel with free radical binding capability, tolerated and was compliant with the protocol and verbalized a reduction in pain.
