BECAUSE OF ITS THIN LAYER of subcutaneous tissue between the skin and bone, the heel is the second most common site for pressure ulcer development (after the sacrum). Heel ulcers are costly and, if not treated promptly and properly, may lead to osteomyelitis and even limb amputation. In this article, I'll describe how to assess patients for risk and take preventive measures. In a future article, I'll describe how to manage ulcers if they develop.
Who's at risk?
Focus your preventive interventions on the Braden scale categories in which the patient has a low score (the lower the score, the higher the risk). Keep in mind, however, that even patients whose total score indicates low risk of pressure ulcer development can develop heel pressure ulcers.
Three groups of patients are at greatest risk for heel pressure ulcers:
- Patients with immobile legs due to health care problems such as fractured hips, joint replacement surgery, spinal cord injury, Guillain-Barré syndrome, or stroke don't move their legs because of paralysis, weakness, or pain. If the foot of the bed is elevated to reduce edema, remember to elevate the patient's knee too, or his leg will be suspended by the heel. Bending the knee provides a level plane of leg elevation, prevents hyperextension of the knee, and relieves pressure on the heels.
- Patients with diabetes may have peripheral neuropathy, which prevents them from feeling pressure or injuries to the feet. Immobile patients with diabetes also may have trouble moving their legs. Carefully monitor these patients and assess their heels twice daily.
- Patients with leg spasms, those in pain, and those who are confused may rub their heels on the bed and abrade the heel. Patients may also dig their heels into the mattress to keep from sliding down in bed, causing further pressure injury.
Heels are difficult to see in supine or chair-bound patients, but inspect them every shift anyway; don't rely on the patient to report heel pain. Lift the leg or use a mirror to see the heels. Teach nursing assistants to inspect heels when dressing or bathing a patient and tell them to report redness, blisters, or bruises. If your patient is wearing compression stockings, remove them at least once a day so you can assess his heels.
The best way to treat heel ulcers is to prevent them. Elevate the patient's calf on a pillow, small towel, or folded bath blanket to suspend the heel off the bed. Make sure you place it under the calf and not under the Achilles tendon. You should be able to place your open hand on the bed under the patient's heel and not feel the skin. Avoid hyperextending the knee and don't use a rolled towel under the Achilles tendon to lift the leg for more than a day or two; you may injure the Achilles tendon.
Devices that elevate the legs work best on patients with immobile legs, such as those recovering from hip and knee surgery or stroke. If your patient is at risk for moving his leg off the device, or if you need to elevate his leg longer than a few days, use a product that stays on the foot during movement.
The best heel pressure-reducing products reduce pressure, friction, and shear; separate and protect the ankles; maintain heel suspension; and prevent footdrop. They should also be comfortable for the patient, easy for you to use, and permit repositioning without increasing pressure in other areas. Remove boots or braces every shift and inspect the patient's skin for redness from the device.
Prevent heel ulcers from abrasion with moisturizers, socks, dressings (such as films or hydrocolloids), or heel protectors. These nursing interventions reduce friction from shearing and rubbing.
Joyce Black is an associate professor of nursing at the University of Nebraska Medical Center in Omaha. Wound and Skin Care is coordinated by Sharon Baranoski, RN, APN, CWOCN, MSN, FAAN, DAPWCA, administrative director of clinical programs and development and administrator of home health care at Silver Cross Hospital in Joliet, Ill., and Elizabeth A. Ayello, RN, APRN,BC, CWOCN, PhD, FAAN, FAPWCA, faculty member at Excelsior College School of Nursing in Albany, N.Y., and senior adviser for The John A. Hartford Institute for Geriatric Nursing in New York, N.Y.
Brenza, D., et al.: “Seating, Positioning, and Support Surfaces,” in Wound Care Essentials: Practice Principles
, S. Baranoski and E. Ayello, Springhouse, Pa., Lippincott Williams & Wilkins, 2004.
National Pressure Ulcer Advisory Panel: “Pressure Ulcers in America: Prevalence, Incidence, and Implications for the Future. An Executive Summary of the National Pressure Ulcer Advisory Panel Monograph,” Advances in Skin & Wound Care
. 14(4):208-215, July/August 2001.
Wound, Ostomy, and Continence Nurses Society: Guideline for Prevention and Management of Pressure Ulcers
. Glenview, Ill., Wound, Ostomy, and Continence Nurses Society, 2003.