Helen Brewah, R.N. - Southampton, UK


This story is my experience caring for a diabetic patient with right below-knee amputation and severe peripheral vascular disease resulting from long-term cigarette smoking.


Mary had been recently discharged from a community rehabilitation hospital. Her blood sugars were poorly controlled, as a result of poor eyesight and insight of her diabetes although she had been diagnosed for many years. It appeared that Mary (pseudonym) had a recent amputation for a leg ulcer which was not improving. She smoked up to 20 cigarettes a day and had been smoking over 40 years. Mary was deemed as non-concordant, and agoraphobic. There was also a grade-4 left heel pressure sore and the left heel was at risk of amputation.


Mary lives with her partner in a rented council accommodation. Both Mary and her partner were known substance misusers but Mary says she has abstained for 1 year. The couple’s house was cold and unkempt, with no food in the fridge, and the mobile telephone was never charged. This indicated that there may have been issues with their finances and management of funds.


On assessment, following informed consent, Mary was able to weight bear on her left leg without much aid. Mary found self-checking her own blood sugars difficult. She was on twice-a-day insulin. The wheelchair allocated to her was of medium standard but used reasonably well. I had a conversation with Mary explaining some of the services that could be made available to her if she consents to them. I explained the benefits of taking part in further physiotherapy in order to enhance her independence. I explained that she will be able to socialize, do her own shopping and prepare her own meals. I explained that the social worker will help with looking at her finances and refer her for a proper financial assessment with a view to ensuring she has satisfactory help to enhance her daily needs such as food, electricity and heating.


We also discussed a referral to a diabetic foot clinic so that her left heel could be treated appropriately, and to the diabetic community care team so we can consider prescribing a once-daily insulin. I told her I would commence a discovery chart, where we will look at her dietary intake in relation to exercise, and what her calorific intake was. I also talked to her about referring her to a psychologist. Mary was clear that her partner prepares her meals and that she did not need any help with this, but her weight was low. I discussed referring her to quit smoking and to attend a weekly patient café, where she would socialize with other long term-condition patients. I offered her a hospital bed and a high-risk pressure-relieving mattress.


Mary was welcoming of all these interventions and declared she was happy to engage and participate. She consented verbally for all referrals to be made but when I discussed this with her general practitioner, she was sceptical that Mary would engage, and stated her reluctance to refer her to a psychologist. There was not much encouragement at all about most of the actions I had offered.


At the time, I felt frustrated that all of this had happened in the first instance, although Mary was a heavy smoker with peripheral vascular disease and poor lifestyle choices. I was also frustrated that she had come out of hospital with another grade 4 left-heel pressure sore with the potential of losing another limb. However, I was optimistic that through integrated working, we would be able to reverse any further risks and prevent further amputations.


It may have come late, but I was pleased we were able to work together in collaboration with the patient who was engaging fully, contrary to some opinions. I was unhappy about the doctor's lack of optimism but I was pleased to see that the patient became fully concordant. I was determined to offer Mary all necessary options to make her journey a comfortable one. I was hopeful that we could help her to achieve independence and I made all the referrals except the psychologist referral, and ordered the necessary equipment. Of course, alternatively, I could have ignored the needs of the patient, which would have made her dependent. Instead, I made her available options known to Mary, who was then able to make an informed choice with possible optimum outcomes.


Mary is now comfortable in a hospital bed and adequate pressure-relieving mattress. The grade-4 left-heel pressure ulcer has not deteriorated further. Smoking cessation is difficult because her telephone is out of order most times. A case conference was held with social services and a financial assessment was done. Mary is now becoming reasonably confident in monitoring her capillary blood sugar, and self-administering her insulin. The GP is considering once-daily insulin. Physiotherapy is in place and Mary has been referred to the amputee clinic with a view to considering a prosthesis. A wheelchair assessment was made, and a suitable wheelchair is on order. The house will be adapted to meet Mary’s needs and the integrated care team will continue to support all of her care needs including care of the grade-4 pressure ulcer.


I learned through this experience that critical thinking and analysis is pertinent in the assessment process. I have learned not to be judgemental of anyone and not to listen to hearsay, but rather to engage directly with the patient. All possible options should be offered to the patient, with all necessary choices made available in terms that patients can understand and the benefits of services should be made known as well. A holistic assessment should always be carried out relating how all factors of life can be affected by one failure. I also learned how to rationalize my decision making, while negotiating for optimum care in the face of resistance and Mary’s case study will now be used in our team’s facilitating learning sessions.


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