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Words on Wounds

A forum to discuss the latest news and ideas in skin and wound care.

Wednesday, May 1, 2019

The Case of the Heel Ulcer
Mona is a 73-year-old woman who was admitted to the hospital with urosepsis and delirium. She was confused and agitated, constantly moving to get out of bed. She developed a heel ulcer on her left leg. How should we describe this?
Heel Ulcer 5-1-19.png
1. What is the etiology? 
This is a large blister over the heel area. The most likely cause of this type of superficial skin damage is related to friction secondary to agitation with excess leg movements rubbing against the bed sheets. The area may also be vulnerable to pressure damage and pressure injury should not be ruled out, because the blister occurred over a the bony prominence.
2. What stage is this? 
According to the National Pressure Ulcer Advisory Panel (NPUAP), a blistered area resulting in the epidermis separating from the dermal layer is a stage 2 pressure injury or ulcer. However, the correct staging will depend on the type of fluid inside the blister. Mona developed a blister filled with murky fluid that is not pus or blood, but providers could not visualize the wound base to determine the level of tissue involvement. This conundrum is not clearly addressed in the NPUAP guideline. Either necrotic tissue or a full-thickness wound were possible and have been seen on the base of similar blisters, prompting providers to call this is a nonstageable wound.
3. What should be done? 
The subject of whether this blister should be drained is highly debatable. Because Mona is mobile, she may choose to have it drained, because the blister may impair ambulation and could burst during a heel strike. It is always better to drain the blister in a controlled environment than having it to rupture accidentally, especially in an unhygienic surrounding. Efforts to offload the heel will be crucial to promote healing and prevent further damage.