Pressure Ulcers on the Heel Require Strict Intervention

ARLINGTON, VA. — Pressure ulcers on the heels present unique challenges, but proactive care can go a long way in preventing these wounds in immobile, elderly people, said Catherine Ratliff, Ph.D., at a meeting of the National Pressure Ulcer Advisory Panel.

The heels are especially sensitive to pressure because there's not much subcutaneous fat or tissue covering the bone in elderly people, explained Dr. Ratliff of the University of Virginia, Charlottesville.

“As we age, the shock absorbency of the foot decreases, which increases the risk of developing a heel pressure ulcer,” she said. Other factors that can increase risk with age include dry skin, leg spasms, and Parkinson's disease, which lead some people to dig their heels in the bed when they attempt to move, said Dr. Ratliff.

She recommended that caregivers assess four factors to determine an individual's risk for heel pressure ulcers: age older than 70 years, diagnosis of diabetes, decreased mental status, and lack of movement in the legs and feet. Also, consider whether individuals are ambulatory, walk with assistance, or are confined to bed, she said.

Caregivers should take some precautions to prevent heel pressure ulcers even in individuals who are at low risk, Dr. Ratliff said. Check the circulation in the affected area, check whether the skin is warm or cool to the touch, examine the feet for redness, and apply moisturizer to the heels. Encourage individuals to get out of bed at least three times a day if possible. If that doesn't happen, consider a pressure-redistributing mattress.

Individuals who are at higher risk, or those who already have a heel pressure ulcer, require stricter interventions, she said. Assess the patient and apply moisturizers more often, work hard to get the individual mobile, and perhaps use devices that take pressure off the heels.

Whether devices such as foam- or air-filled boots are used, the first step in caring for any pressure ulcer is to take the pressure off, said Dr. Ratliff. “It's important to go back and continually reassess the pressure situation.” For instance, blankets or pillows used as cushions can compress over time, she said.

In cases of stage I heel pressure ulcers, caregivers should assess whether shear is a factor and, if so, use moisturizers to reduce friction. It's important to regularly remove any dressing to monitor the ulcer, she added. Other tips include keeping the area warm and assessing whether the patient's bed and footwear might be increasing risk.

Blisters are a concern with stage II pressure ulcers on the heels, said Dr. Ratliff. If a blister pops, trim the surrounding skin, she advised.

For a stage III pressure ulcer on the heel, it's important to monitor the area for signs of infection and, if it develops, to treat with antimicrobials.

“The wound will not heal as long as there is any type of dead slough present,” Dr. Ratliff said. Unfortunately, circulation is an issue in many patients with pressure ulcers, especially older adults. If eschar is soft, it needs to come off, she said. Sometimes hard eschar will lift up by itself, and then it can be trimmed. But don't debride stable, hard heel eschar, she emphasized, because individuals with stable heel eschar have poor perfusion in their legs.

If using any device to relieve pressure on the heels, caregivers should check it periodically to make sure it isn't too tight. Dr. Ratliff added that although some beds have specialized designs meant to reduce pressure on the heels, “raising the bed changes the pressure relief for the heel.”

Dr. Ratliff disclosed no conflicts related to her talk.

ARLINGTON, VA. — Pressure ulcers on the heels present unique challenges, but proactive care can go a long way in preventing these wounds in immobile, elderly people, said Catherine Ratliff, Ph.D., at a meeting of the National Pressure Ulcer Advisory Panel.

The heels are especially sensitive to pressure because there's not much subcutaneous fat or tissue covering the bone in elderly people, explained Dr. Ratliff of the University of Virginia, Charlottesville.

“As we age, the shock absorbency of the foot decreases, which increases the risk of developing a heel pressure ulcer,” she said. Other factors that can increase risk with age include dry skin, leg spasms, and Parkinson's disease, which lead some people to dig their heels in the bed when they attempt to move, said Dr. Ratliff.

She recommended that caregivers assess four factors to determine an individual's risk for heel pressure ulcers: age older than 70 years, diagnosis of diabetes, decreased mental status, and lack of movement in the legs and feet. Also, consider whether individuals are ambulatory, walk with assistance, or are confined to bed, she said.

Caregivers should take some precautions to prevent heel pressure ulcers even in individuals who are at low risk, Dr. Ratliff said. Check the circulation in the affected area, check whether the skin is warm or cool to the touch, examine the feet for redness, and apply moisturizer to the heels. Encourage individuals to get out of bed at least three times a day if possible. If that doesn't happen, consider a pressure-redistributing mattress.

Individuals who are at higher risk, or those who already have a heel pressure ulcer, require stricter interventions, she said. Assess the patient and apply moisturizers more often, work hard to get the individual mobile, and perhaps use devices that take pressure off the heels.

Whether devices such as foam- or air-filled boots are used, the first step in caring for any pressure ulcer is to take the pressure off, said Dr. Ratliff. “It's important to go back and continually reassess the pressure situation.” For instance, blankets or pillows used as cushions can compress over time, she said.

In cases of stage I heel pressure ulcers, caregivers should assess whether shear is a factor and, if so, use moisturizers to reduce friction. It's important to regularly remove any dressing to monitor the ulcer, she added. Other tips include keeping the area warm and assessing whether the patient's bed and footwear might be increasing risk.

Blisters are a concern with stage II pressure ulcers on the heels, said Dr. Ratliff. If a blister pops, trim the surrounding skin, she advised.

For a stage III pressure ulcer on the heel, it's important to monitor the area for signs of infection and, if it develops, to treat with antimicrobials.

“The wound will not heal as long as there is any type of dead slough present,” Dr. Ratliff said. Unfortunately, circulation is an issue in many patients with pressure ulcers, especially older adults. If eschar is soft, it needs to come off, she said. Sometimes hard eschar will lift up by itself, and then it can be trimmed. But don't debride stable, hard heel eschar, she emphasized, because individuals with stable heel eschar have poor perfusion in their legs.

If using any device to relieve pressure on the heels, caregivers should check it periodically to make sure it isn't too tight. Dr. Ratliff added that although some beds have specialized designs meant to reduce pressure on the heels, “raising the bed changes the pressure relief for the heel.”

Dr. Ratliff disclosed no conflicts related to her talk.

ARLINGTON, VA. — Pressure ulcers on the heels present unique challenges, but proactive care can go a long way in preventing these wounds in immobile, elderly people, said Catherine Ratliff, Ph.D., at a meeting of the National Pressure Ulcer Advisory Panel.

The heels are especially sensitive to pressure because there's not much subcutaneous fat or tissue covering the bone in elderly people, explained Dr. Ratliff of the University of Virginia, Charlottesville.

“As we age, the shock absorbency of the foot decreases, which increases the risk of developing a heel pressure ulcer,” she said. Other factors that can increase risk with age include dry skin, leg spasms, and Parkinson's disease, which lead some people to dig their heels in the bed when they attempt to move, said Dr. Ratliff.

She recommended that caregivers assess four factors to determine an individual's risk for heel pressure ulcers: age older than 70 years, diagnosis of diabetes, decreased mental status, and lack of movement in the legs and feet. Also, consider whether individuals are ambulatory, walk with assistance, or are confined to bed, she said.

Caregivers should take some precautions to prevent heel pressure ulcers even in individuals who are at low risk, Dr. Ratliff said. Check the circulation in the affected area, check whether the skin is warm or cool to the touch, examine the feet for redness, and apply moisturizer to the heels. Encourage individuals to get out of bed at least three times a day if possible. If that doesn't happen, consider a pressure-redistributing mattress.

Individuals who are at higher risk, or those who already have a heel pressure ulcer, require stricter interventions, she said. Assess the patient and apply moisturizers more often, work hard to get the individual mobile, and perhaps use devices that take pressure off the heels.

Whether devices such as foam- or air-filled boots are used, the first step in caring for any pressure ulcer is to take the pressure off, said Dr. Ratliff. “It's important to go back and continually reassess the pressure situation.” For instance, blankets or pillows used as cushions can compress over time, she said.

In cases of stage I heel pressure ulcers, caregivers should assess whether shear is a factor and, if so, use moisturizers to reduce friction. It's important to regularly remove any dressing to monitor the ulcer, she added. Other tips include keeping the area warm and assessing whether the patient's bed and footwear might be increasing risk.

Blisters are a concern with stage II pressure ulcers on the heels, said Dr. Ratliff. If a blister pops, trim the surrounding skin, she advised.

For a stage III pressure ulcer on the heel, it's important to monitor the area for signs of infection and, if it develops, to treat with antimicrobials.

“The wound will not heal as long as there is any type of dead slough present,” Dr. Ratliff said. Unfortunately, circulation is an issue in many patients with pressure ulcers, especially older adults. If eschar is soft, it needs to come off, she said. Sometimes hard eschar will lift up by itself, and then it can be trimmed. But don't debride stable, hard heel eschar, she emphasized, because individuals with stable heel eschar have poor perfusion in their legs.

If using any device to relieve pressure on the heels, caregivers should check it periodically to make sure it isn't too tight. Dr. Ratliff added that although some beds have specialized designs meant to reduce pressure on the heels, “raising the bed changes the pressure relief for the heel.”

Dr. Ratliff disclosed no conflicts related to her talk.