Would you take the risk?
The real risk of deep tissue injury on heels.
There is very little padding on our heels which makes it a very high risk area of developing pressure ulcers.
A number of extra risk factors compromising the heel, are diabetes, vascular disease, lymphoedema, conditions causing muscle loss, reduced mobility, friction, poor nutrition and dehydration.
Healing rates for ulcers on the heel can be long, this may be due to the above underlying co-morbidities, or I have increasingly observed as potential part of skin failure at life end. Further research is needed in this field to properly inform the patients and their relatives of the risks.
Amputation risks for ulcers on the heel is high, particularly where there is recurrent infection such as osteomyelitis, gangrenous, or becoming repeatedly systemically infected.
For your diabetic resident it is vital that as part of the SSKIN care plan there is extra emphasis on foot care. For the resident with capacity, explaining to them how they can self care for their feet and the risks, are all part of informed decision making on the residents part.
6 Facts on ulcers on heels of diabetics:
Estimated more than 5 million people by 2025 will have Diabetes
Peripheral arterial disease effects 1:3 people with diabetes over the age of 50
10% of people with diabetes will have a foot ulcer
Foot ulcers precede 80% of amputations in people with diabetes
Up to 70% of those who have amputations die within 5 years
Approx. £1 for every £150 spent in the NHS annual is related to foot ulcers or amputations. (£650 million) (NHS Diabetes 2012.)
So what can you do to prevent?
Individual care planning is essential using SSKIN principles.
While the SSKIN care plan principles prompt us to ensure the principles of prevention are in play. There is no ‘one size fits all’ heel boot.
The risks sometimes may outweigh the use, for example, falls, if the boot is not for ambulatory patients. They may have reduced capacity and attempt to walk with the boot on.
For those in bed 24/7 the boots can get in the way and in some case raising the foot off the end of the bed at an angle placing further pressure on the sacral/coccyx area.
See below taken from our current guidelines from EPUAP/NPUAP/PPPIA:
International Pressure Ulcer Prevention Guidelines NPUAP/EPUAP/PPPIA 2014
Ensure that the heels are free of the surface of the bed
Use heel suspension devices that create a zone of zero pressure for the heel
The knee should be in flexion 5-10 degrees, to avid popliteal vein compression and increased risk of DVT
Avoid pressure to the Achilles
If using a foam pillow ensure that it extends the full length of the calf, and the heel can be maintained free from the surface
Decrease friction and shear. Use slide sheets to reposition and lateral transfer sheets.
Remove anti-embolic stockings regularly in high risk patients to check the heels. Use a large mirror if necessary
Feet should be washed daily and an emollient applied to any dry skin
Apply heel suspension devices according to the manufacturers instructions
If you have any suggestions, comments or want to know more either join the facebook discussion group for Pressure Ulcer Prevention Carer Champion Group (Long term care settings) UK or Pressure Ulcer Prevention QI Leader Group (Long term Care) UK or contact me.
Han P, Ezquerro R. Surgical treatment of pressure ulcers of the heel in skilled nursing facilities: a 12 year retrospective study of 57 patients. J Am Podiatry2011; 101(2): 167–75.