54 JCN 2016, Vol 30, No 3-

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Apressure ulcer involves localised injury to the skin and/or underlying tissue

usually over a bony prominence and as a result of pressure or pressure in combination with shear (European Pressure Ulcer Advisory Panel; National Pressure Ulcer Advisory Panel; Pan Pacific Pressure Injury Alliance [EPUAP/NPUAP/PPPIA], 2014). Partly due to the anatomical location and the pressure exerted upon them, particularly after surgery in immobile patients spending extended periods in bed, heels are the second most common anatomical location for pressure injury (Fowler et al, 2008).

Heels have a particular anatomical structure that reduces the load tolerance they can bear (Cichowitz et al, 2009). Gefen (2010) described this weakness in terms of a specific ‘triad’, where the weight of the foot, the thin soft tissue padding over the calcaneus (heel bone) and the heel’s sharp posterior shape combine to render

The evidence for treating pressure injury located on the patient’s heel

the area fragile to extrinsic forces such as pressure and shear.

If left untreated, heel pressure injuries can involve serious, life-endangering complications such as osteomyelitis (inflammation of bone or marrow, mainly due to infection), septicaemia (blood poisoning), amputation, renal failure and multiple organ failure (Agam and Gefen, 2007). However, Gefen et al (2010) described a lack of studies around biomechanical factors that might affect the aetiology of pressure injuries on the heel.

In the UK, the costs of pressure injuries to the health and social care

Massimo Rivolo, tissue viability nurse consultant; registered manager at Healogics, Eastbourne

KEYWORDS:Heels

THE SCIENCEA pressure ulcer is defined as localised injury to the skin and

underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure injury, although the significance of these is yet to be elucidated (EPUAP/NPUAP, 2009). Once it is established that the skin damage is due to pressure and not for example a moisture lesion, leg ulcer, skin tear or other traumatic damage, it should be categorised (Table 1) and recorded as per local policy and using a validated classification tool (Lloyd-Jones, 2015).

system are estimated to be as high as £1.77 billion per year (Bennett et al, 2004). This means that pressure injuries represent a significant problem, both for patient wellbeing and health service budgets.

HEEL ULCER PREVENTION

When patients spend a lot of time immobilised in bed — following surgery, due to advanced dementia or at end of life, for example — the source of external pressure can involve the bed’s surface, restrictive bed-clothes, or pressure and friction generated when the patient’s legs becomes restless. In these circumstances, as well as high external pressure, the blood flow to the tissue and skin of patient’s heel is reduced (Bergstrom and Braden, 1992).

The EPUAP/NPUAP/PPPIA (2014) guidelines provided some guidance on heel pressure ulcer prevention — for example, in the chapter ‘Skin and tissue assessment’ there is a specific recommendation to check all of the patient’s bony prominences, including the heels.

There is also a clear recommendation to apply prophylactic dressings such as polyurethane foam directly onto bony prominences, including heels, to reduce friction and shear forces. Similarly, evidence © 20

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suggests avoiding the use of pressure-relieving surfaces, such as doughnut-shaped devices, intravenous fluid bags and water-filled gloves; it is also recognised that immobile or bed-bound patients’ heels should be completely offloaded or ‘floated’ on the bed and free of all pressure (EPUAP/NPUAP/PPPIA, 2014).

Where possible, this offloading should be performed using heel suspension devices that elevate the limb and redistribute the weight, with the knee in slight flexion. There is evidence that hyperextension of the knee can cause obstruction of the popliteal vein, which could predispose patients to deep venous thrombosis (DVT) (EPUAP/NPUAP/PPPIA, 2014).

In short, there are a vast amount of recommendations in the literature around preventing pressure, but the author of this article wanted to find similar evidence for treating heel pressure injuries that had already developed.

EVIDENCE

When it comes to finding evidence for the treatment of heel pressure injuries, what is the right question to ask? The author wanted to discover if there was a ‘gold standard’ for treating heel pressure injuries. As a starting point, he scanned the main medical databases including PubMed, CINAHL and Ovid to find out if any strong recommendations were available to inform evidence-based nursing practice (Oxman et al, 1994).

For the searches, the author used key words including ‘heel’, ‘pressure ulcers’, ‘therapeutics’ and ‘treatment’, with specified publication dates between January 1, 1980 and January 31, 2016. Table 2 shows some of the relevant articles found in each database search.

MAIN FINDINGS

A summary of evidence contained in the most pertinent papers is shown in Table 3. However, overall the

research only highlighted the lack of strong evidence available on how to treat heel pressure injuries.

Of the recommendations that were found in the research, one of the clearest was that adherent, dry and stable eschar that has no signs of infection should not be removed as it serves as ‘the body’s natural (biological) cover’ (Agency for Health Care Policy and Research [AHCPR], 1994; Registered Nurses’ Association of Ontario [RNAO], 2007; EPUAP/NPUAP, 2009; EPUAP/NPUAP/PPPIA, 2014).

One prospective study also explored the efficacy of elevating the heel to improve local oxygenation and alleviate the tissue hypoxia associated with heel pressure damage, concluding that ‘elevation is therefore an important technique in pressure ulcer prevention and treatment and should be incorporated into health care practice’ (Huber et al, 2008).The same technique was recommended in the EPUAP/NPUAP/PPPIA (2014)

Table 1: Pressure ulcer categorisation (EPUAP/NPUAP, 2009)

Category Definition

Category one: non-blanchable erythema

This category exhibits intact skin with non-blanchable redness of a localised area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching — its colour may differ from the surrounding area

The area may be painful, firm, soft, and warmer or cooler compared to adjacent tissue. Category one ulcers may be difficult to detect in individuals with darker skin tones

It should also be said that some of the guidance considers category one damage as a sign of pressure ulcer risk rather than actual pressure damage (EPUAP/NPUAP, 2009)

Category two: partial-thickness skin loss

Partial-thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed and without any slough. This kind of damage may also present as an intact or open/ruptured serum-filled blister. The wound will be a shiny or dry shallow ulcer without slough or bruising

This category should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Bruising indicates suspected deep tissue injury

Category three: full-thickness skin loss

This category is defined by full-thickness tissue loss Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed Slough may be present but will not obscure the depth of tissue loss. Undermining and tunnelling may be present

Category four: full-thickness tissue loss

Full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present in some parts of the wound bed and there may also be undermining and tunnelling

Category four ulcers can extend into muscle and/or supporting structures (e.g. fascia, tendon or joint capsules), making osteomyelitis (bone infection) possible. Exposed bone/tendon is visible or directly palpable

It is also important to note that the depth of a category three or four pressure ulcer can vary according to anatomical location. For example, the bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and, therefore these ulcers can be shallow

Sub-categories

Unstageable: depth unknown

Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown), and/or eschar (tan, brown or black) in the wound bed

Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and, therefore category, cannot be determined

Suspected deep tissue injury: depth unknown

Refers to a localised area of purple or maroon intact skin or blood-filled blister, usually due to damage to the underlying soft tissue from pressure and/or shear

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guidelines (see the chapter entitled ‘Repositioning to prevent and treat heel pressure ulcers’ ).

One randomised double-blind study also showed a detrimental effect on the incidence of heel pressure injuries after a local application of 5% DMSO (dimethyl sulfoxide) cream (Houwing et al, 2008), which was supported by the EPUAP/NPUAP/PPPIA (2014) guidelines. DMSO is an antioxidant

cream that is used to diminish the effect of reactive oxygen species (ROS) (ROS are chemically reactive molecules containing oxygen, also commonly referred to as free radicals). In the development of pressure injuries, the release of ROS is a direct effect of the ischaemic process. DMSO is thought to reduce ROS levels and improve local tissue health, but Houwing et al (2008) showed that it can be detrimental for pressure ulcer prevention on the heels. In the study, the incidence of pressure injuries on the heel increased with the use of DMSO, although there was no effect on pressure injuries located on the buttocks.

A randomised controlled trial into oral ornithine alpha-ketoglutarate for treating heel pressure injuries showed some improvement (Meaume et al, 2009). Ornithine alpha-ketoglutarate is an amino acid used as a adjuvant treatment in undernourished people — it is widely recognised that hypocaloric (low calorie) diets and hypoproteinemia (very low levels of protein in the blood) are both risk factors for pressure ulcer development (EPUAP/NPUAP/PPPIA, 2014).

The study showed some reduction in pressure ulcer area after a six-week course of treatment with

ornithine alpha-ketoglutarate, but the evidence was of low quality due to methodological difficulties around the high-age profile of the patients (Meaume et al, 2009).

International guidelines do provide some guidance on how to assess and treat pressure injuries on the lower limb (including the heel), such as vascular assessment, debridement (variously, autolytic, enzymatic, biological, and sharp) and eschar treatment (as mentioned above) (AHCPR, 1994; RNAO, 2007; EPUAP/NPUAP, 2009; EPUAP/NPUAP/PPPIA, 2014). However, overall there is a lack of high quality evidence about the proper treatment for different stages of heel pressure injuries (AHCPR, 1994; RNAO, 2007; EPUAP/NPUAP, 2009; EPUAP/NPUAP/PPPIA, 2014).

CONCLUSION

The brief literature search featured in this article has shown that more good quality studies are required to arrive at a definition of best practice in heel pressure ulcer treatment to guide nurses.

For example, there should be clear indications for healthcare staff about how to treat category one and two pressure injuries, while in category three and four pressure

Table 2: Examples of research located

Main databases searched Pertinent subjects found

PubMed

Increasing heel skin perfusion by elevation (Huber et al, 2008) Treating a pressure ulcer with bioelectric stimulation therapy (Hampton and Collins, 2006)Debridement of necrotic tissue and eschar using a capillary dressing and semi-permeable film dressing (Lisle, 2013)Treatment of a heel blister caused by pressure and friction (Read, 2001)Preventing and managing heel pressure ulceration: an overview (Morton, 2012)

CINAHL

A review of the surgical management of heel pressure ulcers in the 21st century (Bosanquet et al, 2016)Pressure-relieving devices for treating heel pressure ulcers (McGinnis and Stubbs, 2011)Near total calcanectomy with rotational flap closure of large decubitus heel ulcerations complicated by calcaneal osteomyelitis (Boffeli and Collier, 2013) Surgical treatment of pressure ulcers of the heel in skilled nursing facilities: a 12-year retrospective study of 57 patients (Han and Esquerro, 2011) Heel pressure ulcer: stand guard (Langemo et al, 2008)An unexpected detrimental effect on the incidence of heel pressure ulcers after local 5% DMSO cream application: a randomised, double-blind study in patients at risk for pressure ulcers (Houwing et al, 2008)Heel ulcers in critical care units: a major pressure problem (Burdette-Taylor and Krass, 2002)Treatment of a heel pressure sore: a case study (Gray, 2013)

OVID

Managing a necrotic heel pressure ulcer in the community (Clarkson, 2003) Efficacy and safety of ornithine alpha-ketoglutarate in heel pressure ulcers in elderly patients: results of a randomised controlled trial. Randomised controlled trial (Meaume et al, 2009) Make a difference: standardise your heel care practice (Blaszczyk et al, 1998)

Having read this article,

How do heel pressure injuries develop?

What are some of the main methods of heel pressure ulcer prevention?

Your knowledge of the main treatment options available for heel pressure injuries.

Then, upload the article to the new, free JCN revalidation e-portfolio as evidence of your continued learning: www.jcn.co.uk/revalidation

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Blaszczyk J, Majewski M, Sato F (1998) Make

a difference: standardize your heel care

practice. Ostomy Wound Manage 44(5): 32–40

Boffeli TJ, Collier RC (2013) Near total

calcanectomy with rotational flap closure

of large decubitus heel ulcerations

complicated by calcaneal osteomyelitis. J

Foot Ankle Surg 52(1): 107–12

Bosanquet DC, Wright AM, White RD,

Williams IM (2016) A review of the

surgical management of heel pressure

ulcers in the 21st century. Int Wound J (1): 9–16

Burdette-Taylor SR, Kass J (2002) Heel ulcers

in critical care units: a major pressure

problem. Crit Care Nurs Q 25(2): 41–53

Cichowitz A, Pan WR, Ashton M (2009)

The heel: anatomy, blood supply, and the

pathophysiology of pressure ulcers. Ann

for the prevention of this complicated wound development. JCN

REFERENCES

Agam L, Gefen (2007) Pressure ulcers and

deep tissue injury: a bioengineering

perspective. J Wound Care 16(8): 336: 42

AHCPR (1994) Treatment of Pressure Ulcers.

AHCPR Clinical Practice Guidelines, No. 15.

Available online: www.ncbi.nlm.nih.gov/

books/NBK63898 (accessed 11 April, 2016)

Bennett RG, Dealey C, Posnett J (2004) The

cost of pressure ulcers in the UK. Age

Aging 33: 230–5

Bergstrom N, Braden B (1992) A Prospective

study of pressure sore risk among

institutionaliszed elderly. J Am Geriatr Soc

40: 747–58

injuries strategies need to be designed for: Osteomyelitis diagnosis

and treatment Surgical interventions to repair the

wound without putting patients at risk of major amputation

The provision of a thorough vascular assessment before any debridement

Providing proper off-loading casts for ambulant patients

A clear understanding of the local signs of infection.

Dressings should be considered as a last but necessary step in holistic patient assessment, while every effort should be put into risk assessment

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Table 3: Examples of research found on the management of heel pressure injury

Year Source Document Evidence

2014 EPUAP/NPUAP/PPPIA

Prevention and Treatment of Pressure Ulcers. Quick Reference Guide

Wound care debridement Perform a thorough vascular assessment prior to debridement of lower extremity pressure

ulcers to determine whether arterial status/supply is sufficient to support healing of the debrided wound

Do not debride stable, hard, dry eschar in ischemic limbs Assess stable, hard, dry eschar at each wound dressing change and as clinically indicated

2014

National Institute for Health and Care Excellence (NICE)

Pressure ulcers: prevention and management. Clinical guideline 179

Adults: management of heel pressure ulcers Discuss with adults with a heel pressure ulcer and if appropriate, their carers, a strategy to

offload heel pressure as part of their individualised care plan Clinical evidence (adults). Five studies were included in the review and one Cochrane review

was found No randomised trials were identified regarding for example repositioning, electrotherapy,

negative pressure wound therapy (NPWT), debridement, antimicrobials, antibiotics, skin massage or rubbing

2012

Institute for Clinical Systems Improvement (ICSI)

Pressure Ulcer Prevention and Treatment

Implement and document interventions Before performing any type of debridement of the extremities, especially below the knee, the

patient must be assessed for adequate blood supply by palpation of pulses, Doppler, ankle/brachial pressure index (ABPI), non-invasive arterial studies and a review of the patient’s past and present medical history for risk factors for arterial insufficiency

2009 EPUAP/NPUAPPressure Ulcer Treatment. Quick Reference Guide.

Debridement Perform a thorough vascular assessment before debridement of lower extremity pressure ulcers

(e.g. rule out arterial insufficiency) Do not debride stable, hard, dry eschar in ischaemic limbs

2007

Registered Nurses’ Association of Ontario (RNAO)

Assessment and Management of Stage I to IV Pressure Ulcers (Revised). Toronto, Canada

Determine if debridement is appropriate for the patient and the wound Rationale: in some instances debridement may not be appropriate. Situations of this nature

would include a limb or digit that is ischaemic, and where amputation is not possible; these wounds will not heal. In these cases, the necrotic tissue should be kept as dry as possible to prevent odour and infection. The eschar provides a barrier to external contamination in a non-healing wound

The topical application of a drying, antimicrobial agent, such as betadine, may be beneficial. In addition, for some wounds the removal of eschar is not necessary (e.g. small areas on heels and toes)

1994

Agency for Health Care Policy and Research (AHCPR)

Treatment of Pressure Ulcers.

Stable heel ulcers, an exception. Heel ulcers with dry eschar need not be debrided if they do not have oedema, erythema, fluctuance, or drainage. Assess these wounds daily to monitor for pressure ulcer complications that would require debridement (e.g. oedema, erythema, fluctuance, drainage)

The eschar provides a barrier to external contamination in a non-healing wound. The topical application of a drying, antimicrobial agent, such as betadine, may be beneficial. In addition, for some wounds the removal of eschar is not necessary (e.g. small areas on heels and toes)

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60 JCN 2016, Vol 30, No 3

Plast Surg 62(4): 423–9

Clarkson A (2003) Managing a necrotic heel

pressure ulcer in the community. Br J Nurs

12(6 Suppl): S4–12

EPUAP/NPUAP (2009) Pressure Ulcer

Treatment: Quick Reference Guide. Available

online: www.epuap.org (accessed 11

April, 2016)

EPUAP/NPUAP/PPPIA (2014) Prevention

and Treatment of Pressure Ulcers: Quick

Reference Guide. Available online: www.

npuap.org (accessed 11 April, 2016)

Fowler E, Scott-Williams S, McGuire JB

(2008) Practice recommendations for

preventing heel pressure ulcers. Ostomy

Wound Manage 54(10): 42–57

Gefen A (2010) The biomechanics of heel

ulcers. J Tissue Viability 19(4): 124–31

Gray D (2013) Treatment of a heel pressure

sore: a case study. Nurs Res Care Available

online: ww.magonlinelibrary.com

(accessed 11 April, 2016)

Han PY, Ezquerro R (2011) Surgical

treatment of pressure ulcers of the heel

in skilled nursing facilities: a 12-year

retrospective study of 57 patients. J Am

Podiatr Med Assoc 101(2): 167–75

Hampton S, Collins F (2006) Treating

a pressure ulcer with bio-electric

stimulation therapy. Br J Nurs 15(6): 14–18

Houwing R, van der Zwet W, van Asbeck

S, Halfens R, Willem Arends J (2008) An

unexpected detrimental effect on the

incidence of heel pressure ulcers after local

5% DMSO cream application: a randomized,

double-blind study in patients at risk for

pressure ulcers. Wounds. 20(4): 84–8

Huber J, Reddy R, Pitham T, Huber D (2008)

Increasing heel skin perfusion by elevation.

Adv Skin Wound Care 21(1): 37–41

ICSI (2012) Pressure Ulcer Prevention and

Treatment. www.icsi.org/guidelines

(accessed 11 April, 2016)

Langemo D, Thompson P, Hunter S, Hanson

D, Anderson J (2008) Heel pressure ulcers:

stand guard. Adv Skin Wound Care (6): 282–92

Lisle J (2013) Debridement of necrotic tissue and

eschar using a capillary dressing and semi-

permeable film dressing. Br J Comm Nurs

Available online: www.magonlinelibrary.com

(accessed 15 April, 2016)

Lloyd-Jones M (2015) How to categorise

and assess pressure ulcers. Wound Care

Today Available online: www.jcn.co.uk/

wct (accessed 13 April, 2016)

WOUND CARE

McGinnis E, Stubbs N (2011) Pressure-

relieving devices for treating heel pressure

ulcers. Cochrane Database Syst Rev. 7(9):

CD005485

Meaume S, Kerihuel JC, Constans T, Teot L,

Lerebours E, Kern J, Bourdel Marchasson

I (2009) Efficacy and safety of ornithine

alpha-ketoglutarate in heel pressure

ulcers in elderly patients: results of a

randomized controlled trial. J Nutr Health

Aging 13(7): 623–30

Morton N (2012) Preventing and managing

heel pressure ulceration: an overview. Br J

Community Nurs (18 Suppl): S20–2

NICE (2014) Pressure ulcers: prevention and

management. Available at: www.nice.org.

uk/guidance/cg179 (accessed 11 April,

2016)

Oxman AD, Cook DJ, Guyatt GH (1994)

Users’ guides to the medical literature,

VI. How to use an overview. JAMA 272:

1367–71

Read S (2001) Treatment of a heel blister

caused by pressure and friction. Br J Nurs

10(1): 10–19

RNAO (2007) Assessment and Management

of Stage I to IV Pressure Ulcers (Revised).

RNAO. Toronto, Canada

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