The Southern District Health Board clinic has a diabetes nurse specialist, herself, a vascular surgeon, orthopaedic surgeon, a podiatrist and the orthotics team offering a holistic approach to patient-centred care, including optimising diabetes control, effective wound care and infection control, pressure-relieving techniques and ensuring adequate blood flow to the limb.
Aburn believes that if people, when first diagnosed with diabetes, could see the potential impacts on their feet of diabetes complications like neuropathy and peripheral vascular disease, then health professionals may see a lot fewer diabetic foot or lower leg ulcers.
She is a strong supporter of nurses providing quality foot care education right from the outset of diabetes diagnosis and regular foot screening thereafter – annual screening for the low risk and more frequently for those with poorly controlled diabetes, loss of sensation and other risk factors.
She also believes a key message for nurses wanting to help prevent diabetes foot disease is to try and help address the underlying causes of why the person has difficulty controlling their diabetes or is at risk of foot disease. And if the nurse is not a specialist in treating diabetic wounds – or people at risk of them – to promptly refer them to a service or clinic where they can get the specialist care required.
“You can’t muck around with diabetic feet by waiting around to see whether a wound is infected or giving oral antibiotics in the hope it goes away.”
Aburn shares some case studies illustrating how quickly a simple rubbing injury or blister may lead to an ulcer requiring months to heal or the loss of toes or even a foot.
The case studies also show that every wound, like every Kiwi, has a story and Aburn believes it helps to know the ‘story’ or underlying causes if you are going to help somebody successfully heal or avoid another wound in the future.
CASE STUDY: The fashion shoe-lover
A 40-year-old woman newly diagnosed with type 1 diabetes wanted to keep wearing fashion shoes as she had a corporate-type job. Her first blister saw her heel go black; a pharmacist gave her an antimicrobial cream but the infection escalated until she needed a skin graft and was hospitalised for a long time.
The woman had been fit, healthy and had her diabetes well under control until the ulcers developed.
Following her first bad experience she inserted some gel pads into a pair of old fashioned boots in the belief she was doing the right thing. But the pad altered the position of her foot so she ended up with six blisters on her other foot – three of which turned into ulcers.
Because of her job she was very reluctant to wear a moon boot, an off-loading shoe, or go into a total contact cast, so the diabetes foot clinic team had to find a more attractive footwear solution that worked for her.
It took three months to heal the ulcers. After a tough learning curve the woman has not re-presented at the clinic with any more ulcers.
CASE STUDY: The recently widowed
A woman turned up at the diabetes foot clinic with multiple small wounds on her feet. The team discovered she hadn’t been managing herself or her diabetes well since losing her husband. She had lost her appetite, smoked, had peripheral vascular disease and hadn’t been looking after her skin so had callouses and cracks on her feet. The cracks had broken open and bacterial infection had set in.
Recognising the multiple factors behind the wounds, the clinic worked with her to boost her nutrition with supplements and help her sign up to a quit smoking programme with the support of her GP and practice nurse.
A recent clinic appointment showed her wound had taken a turn for the worse and the team discovered she’d had a bad week where she stopped taking her supplements and begun to smoke heavily again.
They sat down and talked with her again about the benefits of eating better and smoking less. They also showed her on the electronically graphed treatment record how her bad week had impacted on the healing of her wound. Seeing the reality on the graph meant the woman agreed to try to cutting back on the cigarettes and eating better to get healing back on track.
CASE STUDY: The whitebaiter
A trim man in his 60s with well-controlled type 2 diabetes had gone whitebaiting at the weekend in his gumboots and got a very small blister on the right side of his foot.
He went to his GP on the Monday and Rebecca Aburn, a district nurse at the time, was assigned to change his dressing on the Wednesday.
“I took the dressing down and there was a very small wound area – probably less than 5mm but the surrounding area was grey and boggy.”
She knew his history included vascular surgery about seven years previously so sent him straight into the diabetic foot clinic. On arrival he was quickly admitted to hospital as his underlying vascular disease had deteriorated, which meant the tiny innocuous gumboot blister had an impact far beyond its actual size. They had to debride his foot back to the bone and he eventually lost two toes. The healing time was more than six months.