Podcast Episode 30: Pressure Ulcers - Part 2

Hello, my name is Sylvie Hampton and welcome to podcast part two, pressure ulcers on the feet. I've had nearly 30 years experience in wound care with most of that time acting as a specialist nurse and I'm now an independent tissue viability nurse consultant working throughout the UK. For simplicity, I've decided to put this podcast into three sections. One, heel and ankle in health, 2. the heel and ankle in arterial disease and 3. the foot in somebody who is diabetic. After the sacrum the most common site for pressure ulcers is the heel, so I'll begin with problems in this area. In the last podcast we reviewed non-blanching or non-whitening under finger pressure redness over a bony prominence. This is a vital assessment as it acts as a warning that a pressure injury could be occurring. So if you have some redness that's appearing there you must take it as a warning and do something about it. The healthy foot. If a patient is unconscious or cannot move even if their arteries are healthy and even if they're on the highest grade mattress they will develop a pressure ulcer. This is because the small bony provenance of the heel is covered by a very small amount of tissue with very little fat or very little blood supply to support it. When in bed and particularly when sitting in a chair with a heel on the floor this small and thin surface is exposed to very high pressures and it's the same with the ankle when side-lying in bed. With the arterial foot, if someone smokes, they are at very high risk of arterial occlusion in the legs, which means that the blood will have difficulty reaching the feet, placing the heel and ankle at much higher risk of pressure injury. Even someone who's reasonably fit and does not smoke may still have arterial disease, which places them at risk. If the blood is not reaching the foot successfully then the capillaries become engorged and turn the foot a dark red, this is called a ruber. The foot may be red for other reasons but if you lift the foot up above the heart and the foot turns white and does not immediately return to red when the foot's lowered then it's very likely to be due to a poor arterial supply. The foot may be white with hairless legs due again to a poor arterial supply. Also if the toe is pinched there should be a white patch where the finger pressed. When released this area should reflush to normal within two to three seconds. If it's longer then it's possible there's an occlusion in the small arteries and if it goes as as long as seven seconds this is becoming an urgent referral to a vascular consultant or a tissue viability nurse. Any lingering redness in the healthy foot or any suspicion of arterial disease in the reddened or white foot particularly if there are blue toes should be urgently referred to a tissue viability nurse for a doppler assessment and this will show if the arterial disease is present and will also show the risk level. In the diabetic foot a patient can most often suffer from neuropathy which really means they lose sensation in the foot and cannot feel if they step on a nail or if their shoe is causing injury by rubbing or if a pressure ulcer is developing from the bed or from the floor. In this case wounds can go completely unnoticed by the neuropathic patient for days or even weeks at a time and this is a very high risk for amputation. Therefore if a patient is not moving or cannot feel they need to move then the heels must always be elevated or floated. This can be achieved simply in bed by the use of pillows placed lengthwise one pillow under each leg with the heel floating free or better still with specialist booties and there's many of those out there. The best selection would be where the boots keep the heel completely free of any pressure. When in a chair, the chair should always keep the legs in a 90 degree flexion as then the feet will be flat on the floor. If you have a chair that's too low or one that's too high, this will encourage the patient to place the heels out in front of them and this will provide very high pressure over the heel. Always, if they're sitting in a chair, have good fitting shoes or slippers. If they're diabetic then the diabetic foot team should assess for appropriate shoes. If there is pressure injuries, particularly in the diabetic foot, then consider the total contact cast, which is a specific casting technique used to heal diabetic foot ulcers and protect the foot. The podiatry team or the diabetic foot team will always know how to apply such a cast. So in conclusion, always check the heels for redness and act. Remember the campaign React to Red which is exactly what we should be doing. We should absolutely be proactive and not reactive to a problem that's already occurred. Always ensure that the heels in a vulnerable person is elevated off of the bed. Always check the bony prominences of the foot for redness on a daily basis and if caught when the redness occurs and this is acted on at that point then a pressure injury will not occur. Thank you very much for listening.