Technology update Preventing pressure ulcers occurring on the heel
Perforating peroneal artery
Lateral branches
Lateral tarsal artery
Posterior branches
Medial calcaneal branches of posterior tibial artery
Figure 1: Arterial blood flow to the heel.
Their combined analysis indicated that specialty air or foam mattresses or overlays reduced the relative risk of developing a heel ulcer by 50% compared with standard hospital mattresses (P = 0.03). When interventions were analysed individually, only the foam mattresses had sufficient evidence of efficacy in preventing heel pressure ulcer development. Variability in the air mattress study results, in addition to the fact that most overlays were compared with other overlays instead of a standard hospital mattress, obscured these results. Vanderwee et al's study[30]
was not in the
meta-analysis. However, they studied 447 patients and found that significantly more subjects developed pressure ulcers on the heels using a viscoelastic foam mattress compared with those on alternating air surfaces.
CONCLUSION Pressure ulcers on the heels occur frequently and lead to significant morbidity and mortality. All bed-bound patients are at risk, and most pressure ulcer prediction scales do not accurately identify the risk factors related to changes in arterial blood flow, neuropathy and lower limb weakness. Heel elevation boots should be used for
high risk patients. Data on which boot is most effective is not available, however, anecdotally, support surfaces do not adequately reduce the risk in the heel.
AUTHOR DETAILS Joyce Black, PhD, RN, CWCN, FAAN, Associate Professor, College of Nursing, University of Nebraska Medical Center, Omaha
Artery of tarsal sinus
References
25. Gilcreast DM, Warren JB, Yoder LH, Clark JJ, Wilson JA, Mays MZ. Research comparing three heel ulcer-prevention devices. J Wound Ostomy Continence Nurs 2005; 32(2): 112–20.
26. Junkin J, Gray M. Are pressure redistribution surfaces of heel protective devices effective for preventing heel pressure ulcers? J Wound Ostomy Continence Nurs 2009; 36(6): 602–08.
27. Adejumo PO, Ingwu JA. Nurses' use of water-filled gloves in preventing heel pressure ulcer in the University College Hospital, Ibadan, Nigeria. Int Wound J 2010; 7(6): 472–9.
28. Meyers TR. Preventing heel pressure ulcers and plantar flexion contractures in high- risk sedated patients. J Wound Ostomy Continence Nurs 2010; 37(4): 372–78.
29. Nicosia G, Gliatta AE, Woodbury MG, Houghton PE. The effect of pressure-relieving surfaces on the prevention of heel ulcers in a variety of settings: a meta-analysis. Int Wound J 2007; 4(3): 197–207.
30. Vanderwee K, Grypdonck M, DeBacquer D, Defloor T. Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions. J Adv Nurs 2007; 57(1): 490–94.
Table 1: Universal heel precautions for all patients at bedrest
1. Inspect feet and heels every shift and document skin integrity of the heel 2. Remove stockings or boots to inspect the posterior heel 3. Do not reapply stockings if they are too tight 4. Palpate quality of pulses in the foot and ankle, and for bogginess/edema in the heel 5. Apply cream/lotion to heels every day 6. Avoid massaging heel prominence
Preventive heel precautions for patients immobilised for over 12 hours Universal precautions, plus: 7. Float heel from the bed on pillows
8. Prevent friction injury in agitated patients with stockings or by applying film/foam dressings to the heel
9. Turn bedridden patients every two hours to remove pressure from the posterior heel 10. Get patient out of bed as soon as possible
11. Teach alert patients an active range of motion enabling them to move the ankle every hour while awake
Strict heel precautions for patients immobilised for over 12 hours Universal and preventive precautions, plus: 12. Float heel from the bed with boots 13. Assess the fit of the boot on each shift, reposition as needed 14. Avoid hyperextension of the knee 15. Perform range of motion exercises including dorsal flexion of the foot 16. Consider use of heel protectors to maintain the foot at 90 degrees ankle flexion 17. Get patient out of bed three times per day if possible
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