From the Guidelines
The best approach for managing a stage three pressure ulcer on the heel of a 91-year-old male involves a comprehensive treatment plan focusing on wound care, pressure relief, and addressing underlying factors. First, completely offload pressure from the heel using a specialized heel suspension boot, pillow elevation, or a pressure-redistributing mattress. Clean the wound gently with normal saline or a non-cytotoxic cleanser during each dressing change, as recommended by 1 and 1. Apply an appropriate dressing based on wound characteristics—typically an alginate or hydrocolloid dressing if the wound has moderate exudate, or a hydrogel if it's drier, changing it every 1-3 days depending on exudate levels.
Key Considerations
- Surgical debridement may be necessary to remove necrotic tissue, though this should be performed by a wound care specialist, with sharp debridement preferred over other methods, taking into account relative contraindications such as severe ischemia, as suggested by 1 and 1.
- Nutritional support is crucial, ensuring adequate protein intake (1.2-1.5 g/kg/day) and sufficient caloric intake, possibly with oral nutritional supplements.
- Pain management with appropriate analgesics before dressing changes is important.
- Regular repositioning every 2-3 hours, even when using pressure-relieving devices, helps prevent further tissue damage.
- Monitor for signs of infection (increased pain, redness, warmth, purulent drainage) and obtain wound cultures if infection is suspected, treating with appropriate antibiotics if confirmed, as guided by 1.
Adjunctive Therapies
Consideration of adjunctive therapies such as systemic hyperbaric oxygen therapy or topical negative pressure wound therapy may be necessary for non-healing ulcers, but their use should be based on the latest evidence and individual patient needs, as discussed in 1 and 1.
Prevention of Recurrence
Determining the cause of the ulceration and implementing measures to prevent recurrence, such as heel protection during periods of bed rest and a comprehensive foot care program, are essential, as emphasized by 1. This multidisciplinary approach addresses the wound directly while supporting overall healing capacity in this elderly patient.
From the Research
Wound Assessment and Management
When managing a stage three pressure ulcer on the heel of a 91-year-old male, it is essential to follow a systematic approach to wound assessment and management.
- A thorough assessment of the patient, the wound, and any other relevant factors must be undertaken before care can be planned 2.
- Accurate wound assessment and appropriate care planning depend on an understanding of the physiology of healing and any factors that may potentially delay or prolong the healing process 2.
- The ABCDEFGHI approach to wound assessment and management can be used to distinguish barriers to wound healing, summarize best practices for wound treatment strategies, and explain the usefulness of complete blood count results during a wound investigation 3.
Wound Assessment Framework
A proposed assessment framework for developing best practice recommendations for wound assessment is the MEASURE framework 4.
- This framework includes key wound parameters such as:
- Measure (length, width, depth, and area)
- Exudate (quantity and quality)
- Appearance (wound bed, including tissue type and amount)
- Suffering (pain type and level)
- Undermining (presence or absence)
- Reevaluate (monitoring of all parameters regularly)
- Edge (condition of edge and surrounding skin)
- Using this framework can help clinicians tailor treatment to the patient's condition and improve wound healing outcomes.
Wound Care Technologies
Recent advancements in wound care technologies, such as AI-assisted assessment of wound tissue, can also be used to support wound management 5.
- These technologies can enable the comparison of images taken at different times, even if they were taken under different lighting conditions, distances, lenses, and camera sensors.
- Automatic wound assessment algorithms can be used to segment the wound area and granulation tissue, providing a thorough assessment of the wound.