Dressing a Diabetic Foot Ulcer at a Sub-centre
Rina is a 19-year-old NSQF Health Care trainee on her first week of practical work at a rural sub-centre in Assam. On Tuesday morning she is asked to change the dressing of a 64-year-old man with a diabetic foot ulcer on his right big toe. The ulcer is oozing pus and has a foul smell. The sub-centre has running water only from 10 a.m. to 11 a.m.; it is now 11:20 a.m. There is one pair of sterile gloves left, two cloth towels, a bottle of 5% sodium hypochlorite, and a puncture-proof container that is already three-quarters full. The patient's son, who has a small cut on his finger, offers to hold his father's leg because the patient keeps jerking it. Rina has not yet been trained on sharps disposal but has seen it done once.
1. List Rina's first five actions in order, from receiving the dressing tray to removing the old dressing, and give the reason for each.
Read the worked answer
- Ask the son to step back and cover his cut. Reason: pus is infectious, and his cut is an entry point; he can still talk to his father from the head end.
- Perform hand hygiene. With no running water, use alcohol-based hand rub if available; if not, use clean water from a covered container and soap, pouring with a mug. Reason: hand hygiene is the single most important step before touching the wound.
- Open the sterile pack and put on the single pair of gloves without touching the outside of the gloves. Reason: gloves protect both Rina and the patient, but she must keep them clean.
- Place a clean towel under the foot and remove the outer bandage with forceps, not fingers. Reason: this reduces contamination and keeps the wound bed undisturbed.
- Inspect the wound before cleaning. Do not pour the 5% sodium hypochlorite directly on the ulcer; it is corrosive and damages new tissue. Use saline or boiled-cooled water if available, and report the stock problem. Reason: cleaning must remove dirt without harming healing tissue.
2. The old dressing, gloves, and soiled towel are in Rina's hands, the waste bin has no lid, and the sharps container is three-quarters full. Explain how she should segregate this waste and why mixing it with general waste is unsafe.
Read the worked answer
The old dressing, gloves, and towel are infectious waste because they are soaked with pus. They should go into a yellow biomedical waste bag, tied when three-quarters full, labelled, and stored in a covered container away from patients and food. If no yellow bag is available, double-bag in a leak-proof bag and arrange collection. The bin without a lid allows flies, rodents, and spillage; Rina should ask for a lidded bin and keep the bag closed. The sharps container must not be used for soft waste, and it should be closed and replaced because it is already three-quarters full; pressing waste into it causes needle-stick injuries. Mixing infectious waste with general waste exposes cleaners and the public, attracts animals, and breaks biomedical waste rules. Rina should report the shortage to the supervisor rather than improvise.
3. The son says, 'I am not afraid; I only want to help my father.' Write what Rina can say to protect him without making him feel rejected.
Read the worked answer
Rina should first thank him and acknowledge his wish to help: 'You are doing the right thing by staying with him.' Then explain simply: 'There is pus on the wound, and you have a cut on your finger. Germs can enter through that cut. I will wear gloves and handle the wound. I need you at the head end to talk to him and keep his hands still.' This gives him a real role, avoids blaming or shaming him, and explains the reason in concrete terms. If he insists, she should not argue; she can offer him clean gloves if available and ask him to cover his cut, but she must not let him hold the leg with an uncovered cut. The aim is to protect him while keeping the patient calm and the family respected.