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Q: What can I do to reduce the risk of heel pressure ulcers in immobilized patients?


A: The heel is second only to the sacrum as the most common site for pressure ulcer development, accounting for 30% of total pressure ulcers. All patients with limited mobility may be at risk for developing heel pressure ulcers. Early intervention and proper treatment are central to managing these wounds.


Risk Assessment

The Braden Scale is an excellent predictive tool for assessing persons at risk for developing heel pressure ulcers. Preventive interventions should focus on those Braden categories in which the patient has a low score. Preventive measures should also be undertaken in patients whose total score indicates they are at risk. Keep in mind that even patients whose total Braden Scale score indicates a low risk of pressure ulcer development may still be at risk for heel ulcers. That is why it is critical to have an individualized plan of care that specifically addresses the Braden scale categories with low scores.


The following patients are at greatest risk for developing heel pressure ulcers:


* patients with leg immobility as a result of hip fracture, joint-replacement surgery, spinal cord injury, Guillain-Barr syndrome, and stroke


* patients with diabetes who have peripheral neuropathy where their ability to feel pressure is altered


* patients with leg spasms, inadequately controlled pain, and mental confusion.




The best management of heel ulcers is prevention. Preventive strategies include recognizing risk, decreasing the effects of pressure, assessing nutritional status, avoiding excessive bed rest, and preserving the integrity of the skin. The following are management strategies aimed at lowering the risk of developing a heel pressure ulcer.


* If the foot of an immobile patient's bed is elevated to reduce edema, the patient's knees should be bent to prevent hyperextension and reduce pressure on the heels.


* Regular screening of patients with diabetes for neuropathy has demonstrated reduced outcomes of amputation and ulceration, and, therefore, is recommended.


* Immobile patients with diabetes and peripheral neuropathy should have their heels assessed twice daily.


* Patients with impaired mental ability should have their heels assessed 2 or 3 times each day in acute care.


* For bedfast patients, use a pillow or foam cushion to raise the heels off the mattress to eliminate the pressure on them. Particular care must be taken, however, to avoid transferring pressure to the Achilles tendons.



Adjunct Devices

In patients at risk, the primary preventive action is to reduce pressure, friction, and shear forces on the heels. The best heel-pressure-reducing products also separate and protect the ankles, maintain heel suspension, and prevent footdrop. Devices engineered to achieve these goals are classified as pressure-relieving (consistently reducing interface pressure to less than 32 mm Hg) or pressure-reducing (pressure less than standard support surfaces, but not below 32 mm Hg).


Pressure-reducing devices can be further classified as static or dynamic. Static surfaces distribute pressure over a larger body surface. Examples include foam mattresses and devices filled with water, gel, or air. Some static support surfaces have a built-in pressure-reducing feature specifically designed to address heel pressure.


For patients who cannot shift positions independently, a dynamic device may be better than a static device. Dynamic devices use a pump that either alternately inflates and deflates the support surface or forces air through fine ceramic balls that act like a fluid and uniformly distribute pressure over the body surfaces.


Air-fluidized beds, categorized as pressure-relieving devices, consistently reduce heel pressure below minimal capillary pressure. However, some benefit may be lost if the head of the bed is elevated to 30 degrees, such as for tube feedings.


A preventive device should be selected on the basis of effectiveness, ease of use, and cost. For purposes of reimbursement, CMS classifies support surfaces in 3 groups. Group 3, air-fluidized systems, are reimbursed for treatment of pressure ulcers but not for prevention of pressure ulcers.


Selected References


Black J. Preventing heel pressure ulcers. Nursing2004 2004;34(11):17.


Brienza D, Geyer M, Sprigle S. Seating, positioning, and support surfaces. In: Baranoski S, Ayello EA, editors. Wound Care Essentials: Practice Principles. Philadelphia, PA: Lippincott Williams & Wilkins; 2004. p 187-210.


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. Adv Skin Wound Care 2001;14:208-15.


Thomas DR. Prevention and treatment of pressure ulcers: What works? What doesn't? Cleve Clin J Med 2001;68:704-7, 710-4, 717-22.


Wound, Ostomy, and Continence Nurses Society. Guidelines for Prevention and Management of Pressure Ulcers. Glenview, IL. Wound, Ostomy, and Continence Nurses Society; 2003.