Cath Lab Digest

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Index: Ostomy Wound Manage. 2008;54(2):62-67.

  Extended care involves numerous medical regimens relevant to diverse concerns such as higher patient acuity, rehabilitation, and terminal illness. Some long-term care facilities offer skilled nursing care comparable to subacute units; rehabilitation is a major focus so patients can gain strength and prepare for discharge to a community setting. The development of pressure ulcers not only thwarts the rehabilitation process, but also lengthens stay, causes unnecessary pain, and financially strains the already burdened medical community.

  The incidence of heel pressure ulcers has been described to range from 19% to 32% in acute care facilities.¹ Common risk factors for their development include immobility of the lower extremities due to cerebrovascular accident, hip fractures, diabetic neuropathy due to diabetes mellitus, structural deformities resulting in pain, and peripheral vascular disease.² Drennan³ observes that the incidence of sacral and trochanteric ulcers may be decreasing but heel ulcer prevalence appears to be increasing; the heel is the second most common site for the development of pressure ulcers.⁴ Due to the thin layer of subcutaneous tissue in this anatomical location, a heel pressure ulcer can develop when a small amount of pressure is exerted on the heel for a short amount of time.⁴ Ulcers can occur from ill-fitting footwear, friction from rubbing feet across sheets, and direct placement of the heels on a support surface. Heel ulcerations can disrupt residents’ mobilitystatus, strip them of their dignity, cause pain, and in some instances result in the loss of a limb due to osteomyelitis.^2,4

  Reducing pressure ulcer incidence is one of the Healthy People 2010 objectives⁵ and the Centers for Medicare and Medicaid Services (CMS)⁵ has designated pressure ulcers as one of three sentinel events for residents in a long-term care facility who have been assessed as being at low risk using a pressure ulcer risk assessment scale. Only patients who are comatose, malnourished, have end-stage disease, or have impaired transfer or bed mobility are considered as being at high risk by the CMS.

  In the Guideline for Prevention and Management of Pressure Ulcers⁶ published by the Wound Ostomy and Continence Nurses Society, pressure ulcers are defined as areas of localized tissue destruction caused by the compression of soft tissue over a bony prominence and an external surface for a prolonged period of time. The National Pressure Ulcer Advisory Panel (NPUAP)⁶ defines Stage I pressure ulcers as “observable pressure-related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy), and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tone the ulcer may appear with persistent red, blue, or purple hues.”

  In an effort to reduce the 22.5% incidence of heel ulcers on a skilled care unit in a long-term care facility, a 1-year program to prevent their occurrence was implemented and evaluated.

Literature Review

  Few studies on prevalence and incidence rates of heel ulcers exist; those available tend to address patients in acute care settings and compare different offloading devices.