Wound Care - A quick step to cellulitis

Athlete’s foot may appear to be a simple fungal infection but it can lead to more serious complications such as cellulitis, writes Bridie O’Sullivan 

By:   Bridie O’Sullivan
 

Planning wound care
  • Full clinical examination
  • Record ankle brachial index to detect arterial impairment
  • Care plan initiated
  • Appropriate dressing chosen
  • Education regarding foot care and prevention of further infection
  • Weight reduction plan
  • Ongoing assessment of progress

Athlete’s foot or tinea pedis is a cutaneous fungal infection that causes the skin to itch, flake and fissure.1 It typically affects the skin between the toes but can occur anywhere on the foot including the toenails. It is more common in people who tend to have moist feet and is one of the most difficult foot conditions to treat.

People suffering from athlete’s foot usually tend to be young males who are reluctant to seek medical advice, believing the condition is too trivial to bother a busy GP with.2

As a result, inadequately treated athlete’s foot may develop into chronic, dry-type tinea pedis that will not respond to topical preparations. In addition, there is the risk of spread of the fungus to other parts of the body.

In the UK, athlete’s foot is present in about 15% of the population, and 1.2 million have a fungal infection of the toenails.1

Cellulitis

Cellulitis is a known consequence of athlete’s foot. It is an infection of the skin and subcutaneous tissues most commonly caused by group A streptococcus and staphylococcus aureus.

In a case-control study of patients hospitalised with cellulitis in France between 1995 and 1996, Dupuy et al highlighted the major role of local risk factors in cellulitis of the leg, namely, lymphoedema and disruption of the skin.3

Furthermore, they concluded that the prevention of tinea pedis could prevent up to 60% of cases of cellulitis.3 These results suggest the importance of treating tinea pedis, especially in patients at risk of recurrences.

Patient profile

Mr Smith, a man in his early 40s, is self-employed and works long hours, spending most of this time standing. He is overweight and suffers from hypertension.

Mr Smith has had athlete’s foot on and off over the past two years. He has used a variety of antifungal agents. Because he neglected to take essential preventative self-care measures, he has suffered recurrent episodes.

Mr Smith had been feeling very unwell one weekend and felt he was getting the flu. He self-medicated with paracetamol for a couple of days until he realised he wasn’t recovering. A visit from his GP diagnosed extensive cellulitis of his right leg that necessitated admission to hospital for medical treatment.

As a consequence of the delay in seeking medical advice, his cellulitis was well demarcated and extended from his tibial tuberosity to his ankle. His leg was red, hot, swollen and painful.

In addition, he had large blisters on the anterior aspect of his leg that had burst, exposing the epidermis. Mr Smith was treated with intravenous antibiotics for several days until the inflammation subsided.

Wound assessment

As a result of his cellulitis and delay in seeking medical advice, Mr Smith developed a large ulcerated area on the anterior aspect of his right leg. It measured 20cm long x 8cm wide; it was sloughy, with copious exudate.

A thorough systematic and accurate assessment was performed to avoid overlooking significant factors. A full clinical examination was performed and ankle brachial index was recorded to detect arterial impairment, as palpating ankle pulses is not sufficient.4

Nursing management

A plan of care was initiated which focused on the management of Mr Smith’s wound and his education needs. The key issues for his management were identified as follows:

The copious exudate was managed with a hydrofibre dressing which maintained the moist wound environment and promoted autolytic debridement.

This was continued until the level of exudate reduced and granulation and epithelialisation was evident. A non-adherent dressing was then used.

In order to promote healing and improve venous return, a compression bandage was applied. A systematic review of clinical trials of compression bandaging found that multilayer bandage systems were the most effective method of achieving compression.6

Consequently, a four-layer compression bandage was applied. This bandage was changed twice-weekly initially, until the level of exudate reduced, and then weekly.

Education

Kershaw suggests that the inclusion of patient (and family) in education is an integral part of any nursing care plan.6 In order for patients to participate in their own care and take responsibility for it, they need knowledge about their health problems.

The nurse needs to be able to define the patient’s learning needs and his readiness for health education. Assessment of the patient’s existing knowledge, cognitive abilities and needs will achieve this.

Mr Smith needed information and education, firstly in relation to his wound, and in the active role he was required to play to promote healing.

Secondly, he needed education about foot care and the prevention of further episodes of athlete’s foot.

Progress

Mr Smith’s wound healed gradually over the next four months. At every dressing change his wound was assessed, care evaluated and documented.

A very important part of the management of this patient was the responsibility he took for his own care. In particular, he needed to rest his leg at regular intervals every day to promote healing.

He also needed to alter his diet and do some regular exercise. Mr Smith participated actively in his care. He was advised in relation to the care of his feet and prevention of athlete’s foot. He was encouraged to visit his GP if he developed any further fungal infections.

Awareness and prevention

There is a need for greater awareness and education among the public on the care of feet and the consequences of fungal infections. This case study highlights the pivotal role the nurse plays in health education.

Bridie O’Sullivan is a ward sister at the Mercy Hospital, Cork

References:

  1. Crawford F et al. Athlete’s foot and fungally infected toenails. BMJ 2001; 322: 288-289
  2. Seaman RAJ. Management of fungal disorders. The skin account. Surrey: Taylor Patten Communications, 1993.
  3. Dupuy A et al. Risk factors for erysipelas of the leg {cellulitis}: case control study. BMJ 1999; 318: 1591-1594
  4. Moffatt C, O' Hare BA. Ankle pulses are not sufficient to detect impaired arterial circulation in patients with leg ulcers. J Wound Care 1995; 4: 34-138.
  5. Miller M, Dyson M. Principles of wound care: a professional nurse publication. London: Macmillan Magazines, 1996.
  6. Kershaw B. Learning – The nurse as educator. In: Wright SG, (Ed). Nursing the Older Patient. London: Chapman and Hall, 1998.
  7. Fletcher A, Cullam N, Sheldon T. A systematic review of compression treatment for venous leg ulcers. BMJ 1997; 315: 576-580.

 


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