Mastering Difficult Heel Ulcers

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A Helpful Guide To Pressure Ulcer Classifications

Classifying or staging pressure ulcers can be confusing as there are many different classification systems. The National Pressure Ulcer Advisory Panel (NPUAD) formulated guidelines that could function as a universal model.3 The panel offers the following four-stage system of classifying these lesions.

Grade One: This grade is characterized by non-blanchable erythema on intact skin. Discoloration of the skin, warmth, edema, induration or hardness may also be indicators, particularly in individuals with darker skin tones.

Grade Two: This stage represents a partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion or blister.

Grade Three: This stage represents a full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through the underlying fascia.

Grade Four: These lesions reveal extensive destruction, tissue necrosis or damage to the muscle, bone or supportive structures with or without full thickness skin loss.

Ulcerations that appear necrotic and dry cannot be staged.

Patient #1, a 79-year-old Caucasian male, presented with a non-healing, three-month old wound at the medial aspect of his left heel.
Here is the same wound after offloading was used throughout the treatment course and after the authors applied Apligraf. Dr. Snyder notes Apligraf augments the healing process by “bathing the tissue with growth factors” and stimulating granulation tissue.
This three-week old pressure ulceration began as a blister for Patient #3, an 80-year-old Caucasian female, but the blister became necrotic and exceedingly more painful.
Here you can see the same wound after vascular surgery, debridement and Apligraf application
Here is a healed wound 10 weeks after the authors had applied the skin graft.
By Robert J. Snyder, DPM, CWS, and Heather Perrigo, RN

Pressure ulcer disease represents a significant medical problem both nationally and internationally. Approximately 1.7 million people in the United States develop these maladies at an annual cost of between $2.2 billion and $3.6 billion.1 With the population aging, assisted living and nursing facilities flourishing and obesity creating catastrophic increases in diabetes and other diseases, it is likely the number of ulcerations will continue to increase.
The pressure ulcer is an area of localized damage to the skin and underlying tissue caused by pressure, sheer, friction and/or a combination of these conditions. These lesions were initially characterized as unfortunate sequella of seriously ill patients; however, they often take on a “life of their own,” leaving catastrophe in their wakes.2
Pressure wounds are often predicated on multiple medical diagnoses, age, impaired mobility and decreased mental status. Poor nutritional status, incontinence and impaired circulation are also important indicators. Particularly vulnerable groups include patients with spinal cord injuries, diabetes and patients who have had orthopedic surgery. You should give additional consideration to ICU patients and elderly patients, especially those suffering from dementia, malnutrition, a history of previous ulcerations, low ejection fractions and incontinence.4
The heel is particularly prone to pressure ulcer defects, in part because of its relatively lower resting blood perfusion levels, higher amounts of surface pressure when under stress, and the possibility of compromised local blood flow if the patient has lower extremity arterial disease.5
Depths range from persistent reddened or blue areas of intact skin to very deep destructive wounds with significant tissue loss. Wound bed appearance may vary. Extensive necrotic tissue with significant undermining and tunneling is common. Lesions in the sacrum or coccyx areas may appear as inverted cones with the apex at the skin surface. Underlying bone may be affected and exudates may vary.
Well-defined wounds frequently conform to the underlying bone and therefore appear irregularly shaped. You’ll usually see this phenomenon in the large truncal areas. The surrounding skin is usually dry. Maceration secondary to incontinence or excessive perspiration may be an issue in sacral or coccyx areas. Infected ulcers may exhibit periwound erythema and edema. Drainage may be prevalent and copious. The degree of pain varies.

Key Tips On Nutritional Testing
Healing is predicated on eliminating or reducing pressure, shear and friction, and implementing appropriate skin care.6 Nutritional protocols are important and you should monitor them carefully. Albumin and pre-albumin studies are useful in assessing protein deficiencies. Serum albumin is often used as a basic screening measure for malnutrition. However, because of its relatively long half-life of 18 days, it reflects long-term change and is not a sensitive marker of current nutritional status. Hydration and age affect this test as well. A value of less than 3.5 g/dL is generally indicative of poor nutritional status.7
The pre-albumin has a shorter half-life of two to three days, responds to changes in nutrient balance within seven days and can be performed regularly.8 Indeed, this blood study represents a better indicator of nutritional status. You can monitor dietary interventions and change them accordingly. Studies including serum transferrin and total lymphocyte counts (TLC) may also be of benefit. Order a nutritional consult if you suspect deficiencies.

Pinpointing Areas Of Emphasis In Treatment
Treatment options include meticulous nursing care (i.e. turning patients every two hours, appropriately lubricating the skin), nutrition and hydration, mobility, pain management and meticulous wound care, including medical and surgical interventions. Educating both the patient and family is critical and should be an ongoing effort.9
With all of this in mind, let’s take a closer look at four challenging case studies involving difficult heel ulcers.

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