Causes of heel pressure ulcers - Essay Example

Causes of Heel Pressure Ulcers Asha Kuruvila Of Nottingham 29/01/07 Contents INRODUTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 2. PRESSURE ULCER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2.1 SURGIAL RISK FATOR . . . . . . . . . . . . . . . . . . . . . . 6 3. FURTHER RESEARCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 4. HEEL ULCER. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 5. PRACTIE RECOMMENDATIONS . . . . . . . . . . . . . . . . . . .. . . 12 6. CONLUSION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 LIST OF REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1. INRODUTION The central aims of this assignment are to critically analyze topic of causes of heel pressure ulcers and aspects of contemporary practice from authors clinical specialty and promote clinical effectiveness of current practice, through an action plan. This will aid the discovery of key areas that require practice development. Pressure ulcers among elderly hospital patients diminish quality of life and increase the cost of hospital care. The development of ulcers on heel area is a serious problem, requiring lengthy hospital stays and periods of disability, and often leads to lower limb amputation. Management of heel ulcers requires a thorough knowledge of the major risk factors for ulceration in the heel region. . The most common risk factors for ulceration in the heel region resulting from a combination of several problems including neuropathy, inadequate blood supply, and abnormal pressure on the heal bones. Problems of the heel ulcer are the threesome of neuropathy, diabetes, and ischemia. Patients determined at high risk for heel ulcers or ulcers at any other location where prolonged pressure may contribute to tissue ischemia and damage require immediate treatment with pressure-reducing or pressure-relieving devices. Ischemia not only has a role in the etiology of the heel ulcer, but also after the ulcer has formed, the blood supply required to heal it is several times more than is necessary for the previously intact skin. Heel ulceration, on average, costs 1.5 times more than metatarsal ulceration; limb salvage of the heel is two to three times less likely than metatarsal salvage. The exact incidence of diabetic heel ulcers is not known, but the incidence of pressure heel ulcers in patients with and without diabetes ranges from 19% to 32%. Forefoot surgery usually leads to rehabilitation, while heel surgery more often leads to limb loss and functional disability. The heel is the second leading site for development of pressure ulcers after the sacrum. The causes of the heel pressure ulcers are the chosen topic as the author works with in a general rehabilitation unit where the majority of causes of heel ulcers are due to immobility, Heel pressure ulcers are painful, can take up to several months to heel, and may contribute to other serious complications such as cellulites, osteomyelities, and loss of the affected limp or even death (Tourtual et al 1997). Marlin (2000) state that heel pressure ulcers can cause prolonged recovery and increased length of hospital stay results in a lengthened rehabilitation phase and causes a delay in return to normal daily activities. Main Body Surgical procedures increasingly have been recognized as an important risk factor in the development of pressure ulcers. A limited but developing body of knowledge supports the fact that numerous surgery-related factors are associated with pressure ulcer risk. Patients undergoing cardiac surgery have been identified as being at higher risk than surgical patients overall. Patients who undergo cardiac surgery were found to have additional identifiable risks for developing pressure ulcers. The research question is clearly defined with in the introduction and this gives a clear focus to the paper. The problem is clearly identified and although there have been great improvement in this area the researcher has still found a gap in the way nurses deal with heel pressure ulcers (Lisette et al 1998). The study design is not clearly stated but the data collection method is of the observational nature, which is a classic qualitative research method (Cormack 1996). The subjects were observed for skin changes the day before the surgery and subsequently continued for 14 days or until discharge, whichever occurred first. A qualitative method was used as this gives a subjective view of how the researcher deal with size, colour of the lesion, stage and skin condition, providing a more descriptive means to the research. There are strength and weakness to this kind of study, observer bias is an issue, with in this study the data were collected by researcher and nurses, who had specific training, to enhance the reliability and validity of the study (Cormack 1996). However, due to different people collecting data there will be mild significance difference in result. Another limitation is that amount of time it takes to collect observation data in real life settings (Cormark2000). Even though the sample size was adequate the researcher is not mentioned the method they used to select the sample. Pressure ulcers developed mainly on the heels and on the sacrum in patients who were in spine position during surgery (Kemp et al 1990). The ethics committee of the hospital approved the study (Department of health 2001). The results are given in table format, which tell us the percentage of pressure ulcers in different body parts. Forty-four subjects developed 70 pressure ulcers in the first 2 days following surgery, more than half (52.9%)of the lesions developed on the heels (Lisette et al 1998), because heels have a small surface area and thin layer of subcutaneous tissue between the skin and bone they are prime sites for pressure ulcer development (Tymec et al 1997). Brooks and Duncan (1940) stated that pressure only slightly below that necessary to render a part totally anoxic may result in massive necrosis if the application time is prolonged. This shows that long surgical procedures can cause heel pressure ulcers. However, it should be noted that Brooks and Duncan's study was an animal in vitro experiment. Research has shown that the chance of developing pressure ulcers at least doubles in operations lasting longer than 4 hours (Hicks, 1970: Hoshokey & Schramm, 1994). In one study, a pressure ulcer rate of 45% was reported in 33 patients who underwent surgical procedures lasting longer than 10 hours. In another study, there was a 21.2% incidence of pressure ulcer occurrence in the first two days after surgery. In a study of older adult patients with hip fractures, a pressure ulcer incidence rate of 66% was reported, though this has been recognized more recently as an interpretive inaccuracy. Given the lack of research, one researcher raised the question of whether the pressure ulcer prediction and prevention algorithm developed is applicable to surgical patients. Following a national study of intraoperatively acquired pressure ulcers, researchers concluded that all surgical patients should be considered at-risk. Surgery seems to be a risk factor, even in subjects who are not at risk (Vermillion, 1990). Most pressure ulcers that develop post operatively are painless and heels are unnoticed (Papantonio et al 1994). (The author has explained in detail regarding prevention of heel pressure ulcers in her presentation). Bliss & Simini (1999) mentioned that guidelines for postoperative management rarely recommend pressure-relieving support in high-risk situations. Further studies on use of pressure -reducing mattresses &, heel protectors on operation table are indicated to provide more evidence for these recommendations. This study shows that pressure ulcer development especially on heels during surgery is a serious problem, therefore it is a crucial part of nursing intervention to take preventive measures during and first few days afterwards until patients are able to mobilize themselves independently. Versluysen examined pressure ulcer development in 100 elderly patients (aged 70-94 years) with hip fractures. All patients, who were monitored from their arrival at A&E, had spent at least two hours on a trolley or in theatre on an operating table. Seventy-two patients spent two or more hours on a trolley with no pressure relief and eight patients spent more than two hours on an operating table. Eighty-three developed pressure ulcers within five days of admission, suggesting that the tissue damage that occurred when they were on a trolley or an operating table could have resulted from a reduction in collagen or subcutaneous tissue, or vasculature alterations caused by atrophy and thinning of the vessel walls and a reduction in the vascular beds. All of these factors reduce tolerance to pressure and shear. Studies show that subjects with fractured hip has high risk for heel pressure ulcer development (Kosiak, 1996). What is the most essential aspect of treating a pressure ulcer The heel has been identified as the second most common site, marking up 28% of all reported pressure ulcers (Barczak et al, 1997). The most important component of pressure ulcer care is daily examination of the pelvic, sacral, and heel areas. Any break in the skin is an emergent situation. It must be immediately documented and a plan should be initiated. Early recognition and intervention are vital to successful treatment. Department of Veterans Affairs podiatry clinic conducted study on the location of foot ulcerations via a retrospective chart review of diabetic patients and correlated location of ulceration with specific medical parameters. The heel was a site of ulceration in 11% of the patients. Heel ulcers in diabetic patients as well as non-diabetic patients are associated with a high morbidity rate in hospitalized or debilitated patients. Pressure, peripheral vascular disease, trauma or neuropathy are a few of the causes often associated with heel ulcers. By multiple logistic regression, patients with diminished vascular function were more than five times more likely to have heel ulceration than patients with adequate vascular status. Frykberg et al. reported that 39 percent of a cross section of individuals with diabetes and peripheral neuropathy had plantar-pressure ulcerations. (Frykberg RG, 1998).The objective of Frykberg et al study was therefore to ascertain the risk of ulceration associated with high foot pressures and peripheral neuropathy in a large and diverse diabetic population. They studied a cross-sectional group of 251 diabetic patients consisting of 121Caucasian, 36 black, and 94 Hispanic racial origins with an overall age 20 to83 years .There was an equal distribution of men and women across the entire study population. All patients underwent a complete medical history and lower extremity evaluation for neuropathy and foot pressures. The mean dynamic foot pressures of three footsteps were measured using the F-scan mat system with patients walking without shoes. They conclude that both high foot pressures and neuropathy are independently associated with ulceration in a diverse diabetic population, with the latter having the greater magnitude of effect. In black and Hispanic diabetic patients especially, joint mobility and plantar pressures are less predictive of ulceration than in Caucasians. (Frykberg RG, 1998) Although heel ulcers are less frequent than forefoot ulcers, higher expenses and higher morbidity rates are associated with heel ulcers. The importance of understanding the risk factors for heel ulcerations stems from the lack of available treatments for heel ulcerations. Apelqvist et al. reported that the incidence of heel ulceration was 13 percent in a population of 314 individuals. Clinicians must recognize the potential for heel ulcerations, especially in patients. (Apelqvist J, 1989). Moulik P K, Mtonga R and Gill G V studied the patients presenting with new ulcers, duration less than one month to a dedicated diabetic foot clinic between 1994 and 1998. Outcomes were determined until March 2000 (or death) from podiatry, hospital, and district registers. Baseline clinical examination was done to classify ulcers as neuropathic, ischemic, or neuroischemic. Out of 185 patients studied, 41% had peripheral vascular disease (PVD) and 61% had neuropathy; 45%, 16%, and 24% of patients had neuropathic, ischemic, and neuroischemic ulcers, respectively. They concluded that all types of diabetic foot ulcers are associated with high morbidity and mortality. The increased mortality appears to be independent of factors increasing ulcer risk-that is, neuropathy and PVD-in patients with established foot ulcers. (Moulik P K, Mtonga R & Gill G V, 2003). Treatment of foot ulcers includes treatment of the diabetes itself. Management of contributing systemic factors, such as hypertension, hyperlipidemia, atherosclerotic heart disease, obesity, or renal insufficiency, is crucial. Management of arterial insufficiency, treatment of infection with appropriate antibiotics, offloading the area of the ulcer, and wound care are also essential. In the presence of an intractable wound and associated noncorrectible ischemic arterial disease, hyperbaric oxygen therapy may be beneficial (in selected cases).The management of diabetic foot ulcers requires appropriate therapeutic footwear, daily saline or similar dressings to provide a moist wound environment, debridement when necessary, antibiotic therapy if osteomyelitis or cellulitis is present, optimal control of blood glucose, and evaluation and correction of peripheral arterial insufficiency. (Richard M Stillman, 2006) 5. PRACTIE RECOMMENDATIONS There are a few uncomplicated clinical practices, which the health professional can follow to prevent pressure ulceration. Assessment 1. A head-to-toe skin assessment should be carried out with all clients at admission, and daily thereafter for those identified at risk for skin breakdown. Particular attention should be paid to vulnerable areas, especially over bony prominences. 2. The client's risk for pressure ulcer development is determined by the combination of clinical judgment and the use of a reliable risk assessment tool. 3. Clients who are restricted to bed and/or chair, or those experiencing surgical intervention, should be assessed for pressure, friction and shear in all positions and during lifting, turning and repositioning. The common practices include determining the level of patient risk, the method for redistribution of patient body weight, and restoration of tissue tolerance, metabolic balance and adequate nutrition. When these patient care factors are addressed successfully the likelihood of preventing pressure ulceration is greatly enhanced. Treatment for Pressure ulceration requires improvement! The emphasis has to be on educational programs teaching the preventative methods, which will lead to a reduction of incidence of pressure ulcers. Educational programs for the prevention of pressure ulcers should be structured, organized, and comprehensive and should be updated on a regular basis to incorporate new evidence and technologies. Programs should be directed at all levels of health care providers including clients, family or caregivers. Nursing best practice guidelines can be successfully implemented only when there is adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Thus the goals of nursing care are to protect against the adverse effects of external mechanical forces through the use of specialised pressure removing devices, mattresses, etc, and to improve tissue tolerance through attention to nutrition. The main approach to preventing pressure ulcers was identified as pressure redistribution (pressure reduction or pressure relief). Pressure redistributing equipment is limited and one could question their overall effect - particularly if the rising incidence of heel ulcers is used as a barometer of efficacy. It is therefore important for nurses to rigorously examine current practice and where necessary, carry out and disseminate original research to inform or confirm good practice. In doing this, nurses will be able to broaden their understanding of pressure ulcer prevention and establish a scientific basis for cost-effective care which does not compromise quality. 6. CONLUSION Heels are at high risk of pressure damage, particularly amongst older people who are acutely ill and immobile. The incidence of pressure damage on heels appears to be on the increase from 19% in 1989 to 30% in 2001. The population is getting older and there are growing numbers of elderly frail people so it is very important that practitioners ensure they receive cost-effective preventive care. In conclusion, reduction in the incidence of pressure ulcers would have enormous cost-benefits for patients in terms of quality of life, and the National Health Service in terms of performance and expenditure. Pressure ulcer prevention is therefore, a fundamental aspect of nursing practice, particularly within specialties, which care for acutely ill, immobile older people. Heels are built to withstand high levels of pressure, their ability to manage load may be time- and health- dependent. Elderly and acutely ill patients are at high risk of developing heel pressure ulcers and there are huge human and financial costs. These not only cause a great deal of pain for the patient and can be associated with serious morbidity but they are very expensive to treat. References Apelqvist J, Castenfors J, Larsson J, Stenstrom A & Agardh CD. (1989) Wound Classification is More Important than Site of Ulceration in the outcome of diabetic foot ulcers. Diabetic Med.6 (6):526-30. Brooks, B., Duncan, G.W. Effects of Pressure on Tissue. Arch Surg 1940; 40: 696-709. Catherine Anne Sharp & Mary-Louise McLaws. (2005). A Discourse on Pressure Ulcer Physiology: The Implications of Repositioning and Staging. University of New South Wales, Sydney. [Online] Available at http://www.worldwidewounds.com/2005/october/Sharp/Discourse-On-Pressure-Ulcer-Physiology.html Frykberg RG, Lavery LA, Pham H, Harvey C, Harkless L & Veves A.(1998). Role of Neuropathy and High Foot Pressures in Diabetic Foot Ulceration. Diabetes Care. 21(10):1714-19. Hanson & Langemo D. (2001). Quality Indicators for Prevention and Management of Pressure Ulcers in Vulnerable Elders. Journals of Internal Medicine: 110-135 Kosiak .M.(1996). An Effective Method of Preventing Decubital Ulcers. Arch Phys Med Rehab. 47:724-9. Moulik P K, Mtonga R & Gill G V. (2003). Amputation and Mortality in New Onset Diabetic Foot Ulcers Stratified by Etiology. Diabetes Care 26(2): 491-4. Nidal A. Younes, Abla M. Albsoul & Hamzeh Awad. (2007) Ostomy Wound Management.Diabetic Heel Ulcers: A Major Risk Factor for Lower Extremity Amputation. [Online] Available at http://www.o-wm.com/article/2737 Polit, D.F and Hungler, B.P. (2000) .Essential of Nursing Research Methods, Appraisal and Utilisation.4th ed.Philadelphia: Lippincott-raven Publishers. Richard M Stillman. Wound Healing Center, Department of Surgery. Northwest Medical Center. [Online] Available at http://www.emedicine.com/med/topic551.htm Schoonhoven L, Defloor T and Grypdonck MHF. (2002). Incidence of Pressure Ulcers due to Surgery. Journal of Clinical Nursing. 11,479-487. Tymec C, Pieper B,Vollman K.A. (1997)Comparison of Two Pressure- Relieving Devices on the Prevention of Heel Pressure Ulcers. Adv Wound Care. 10:39-44. Versluysen M. (1986).How Elderly Patients with Femur Fractures Develop Pressure sores in Hospital. British Medical Journal 292:1311-13 Read More