What is the best initial step for an older client with diabetes and a heavily draining leg wound, with leukocytosis (elevated white blood cell count) but no fever?

Management of Diabetic Foot Infection with Heavily Draining Leg Wound

The nurse should immediately refer the older client with diabetes, heavily draining leg wound, and elevated white blood cell count to a wound care specialist for urgent assessment and management. 1

Assessment and Initial Management

Infection Severity Assessment

• The elevated white blood cell count of 38,000/mm³ indicates a severe infection, even in the absence of fever 1
• Diabetic foot infections should be diagnosed clinically based on purulent secretions or at least two cardinal manifestations of inflammation (redness, warmth, swelling, pain) 1
• Heavy drainage from the wound suggests active infection requiring prompt intervention 1

Immediate Nursing Actions

• Collect wound cultures before initiating or changing antibiotic therapy to guide treatment decisions 1
• Implement contact precautions to prevent cross-contamination, as heavily draining wounds pose infection control risks 1
• Document wound characteristics including size, depth, appearance, and drainage 1
• Assess vascular status by checking pedal pulses, capillary refill time, and signs of ischemia 1

Specialized Care Requirements

Wound Care Management

• The wound requires professional debridement to remove necrotic tissue and reduce bacterial load 1
• After culture collection, the wound should be cleansed and appropriate dressings applied based on wound characteristics 1
• Dressing selection should address the heavily draining nature of the wound, with alginates or foams being appropriate for exudative wounds 1

Multidisciplinary Approach

• Prompt referral to a specialized diabetic foot service is indicated within 24 hours for this severely complicated diabetic foot ulcer 1
• The patient requires evaluation by a multidisciplinary team including wound care specialists, infectious disease experts, and vascular surgeons 1
• Hospitalization may be necessary given the severity of infection indicated by the markedly elevated white blood cell count 1

Ongoing Management Considerations

Infection Control

• Empiric broad-spectrum antibiotics may be initiated after cultures are obtained, with adjustment based on culture results 1
• Regular wound assessment is essential to monitor for signs of worsening infection or need for surgical intervention 1

Prevention of Complications

• Pressure offloading is crucial to promote healing and prevent further tissue damage 1
• Vascular assessment should be performed to evaluate for peripheral arterial disease that may impair healing 1
• Blood glucose management is essential as hyperglycemia impairs wound healing and immune function 1, 2

Patient Education

• While patient education about potential complications including amputation is important, this is not the priority initial nursing action 1, 3
• Education should focus on the importance of specialized wound care, infection management, and glucose control 1, 3

Common Pitfalls to Avoid

• Do not delay referral to specialized care - early intervention by a wound care specialist is associated with better outcomes 1, 3
• Do not focus solely on the absence of fever - severe infections in diabetic patients may present without fever 1
• Do not administer acetaminophen as the first intervention, as the patient is afebrile and the priority is wound management 1
• Do not rely on superficial wound swabs alone for culture; deeper tissue samples provide more accurate results 1