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Cheatography

Heal Pressure Ulcers Cheat Sheet (DRAFT) by [deleted]

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Introd­uction

Heel ulcers are the second most common site for pressure ulcers with associated incidence on the rise. As indivi­duals live longer, enter hospitals with multiple co-mor­bid­ities and complex care needs, and undergo more surgical procedures at advanced age, they are at higher risk — partic­ularly when hip and lower extremity orthopedic procedures are required.

Heel Vulner­ability

The calcaneus bone is the largest in the foot and is wide in relation to its associated skin surface area.
Little subcut­aneous fat surrounds the calcaneus. The shock absorptive capacity of the heel decreases with age, leaving it more suscep­tible to forces of pressure, friction and shear.
Because the sole of the foot has no sebaceous glands, the lack of lubric­ation leaves the skin more vulnerable to drying and cracking.
Peripheral vascular changes in the patient with diabetes can cause narrowing and hardening of blood vessels, partic­ularly in the legs and feet.
Decreased blood flow results in damage to nerves (neuro­pathy) and reduced tissue tolerance to pressure.
Loss of sensation, secondary to diabetic neurop­athy, can prevent patients from feeling ischemic pain that causes a normally sensate patient to move his or her leg to relieve the pressure and stop the pain.
Additional factors that put the heel at risk include circul­atory impair­ment, athero­scl­erosis of vessels, as well as vascular, ischemic and obstru­ctive insuff­ici­encies.

Other Clinical Factors

Heels are often overlooked during nursing skin assess­ments, both on admission and during the hospital stay.
The most commonly used risk assessment tools do not have a sub-scale for non-mo­vement of lower extrem­ities, meaning they typically do not address the specific risk factors respon­sible for the develo­pment of heel pressure ulcers.
Because heels are not incont­inent, they do not require the frequent assess­ment, cleansing and lubric­ation that is associated with an incont­inent patient.
Patients with diabetes are four times more likely to develop a heel ulcer.
 

Risks

History of previous heel ulcer
Immobility
Multiple co-mor­bid­ities (emphasis on diabetes mellitus)
Devices that place pressure on heels (TEDS, traction, CPMs, compre­ssion hose)
Lower extremity vascular disease
Vasoco­nst­rictive drugs and sedation used in critical care
Epidural and general anesthesia
Lower extremity contra­ctures that lead to constant unrelieved pressure
Lower extremity orthopedic surgeries
Lower extremity edema
Ventilator dependency
Agitation that results in friction and tissue distortion to heel skin
Prolonged operative procedures without adequate heel protection

Prevention

Be aware of all of the risk factors for heel pressure ulcer develo­pment, including a Braden mobility score of three or less and a patient’s inability to lift their foot off the bed unassisted or reposition indepe­ndently
Assess and document heel skin integrity on admission and during each shift
Treat dry skin with a skin moistu­rizer twice daily to decrease friction and shear
Institute regular and frequent reposi­tioning of the extremity
Float heels of at-risk patients: position pillows lengthwise from the knee to just above the heel, suspending heel off the support surface for short-term interv­ention
Consider protective heel boot if prolonged inactivity occurs (i.e., greater than six hours)
Provide range-­of-­motion exercises to ankles every 12 hours and as needed
Remove TED stockings, CPMs, compre­ssion hose and ace wraps per facility protocol for skin assess­ments
Mobilize patients as soon as possible
Consult wound ostomy continence nurse if patient develops a heel ulcer or deep tissue injury
Consult physical therapist if patient has foot drop or is at risk for developing a plantar flexion contra­cture at the ankle
Protect heels at risk during times in the operating room and long stays in emergency depart­ments