From the Guidelines
Management of a black, intact pressure injury on the heel involves careful assessment and conservative treatment, prioritizing offloading and wound care to prevent further complications and promote healing. The first step is to determine if the black tissue is stable, dry eschar or if there are signs of infection or fluctuance underneath 1. It is crucial not to debride stable, dry eschar on the heel unless there are signs of infection, as the heel has limited soft tissue between skin and bone. Keeping the area clean and dry, and offloading pressure completely by using heel suspension devices, pillows, or specialized boots that prevent the heel from touching any surface is essential 1. Monitoring the wound closely for changes in size, drainage, odor, or surrounding skin condition, and maintaining adequate nutrition and hydration to support healing are also vital. If the eschar becomes unstable, softens, or shows signs of infection, seeking immediate medical attention for possible surgical debridement is necessary. Regular repositioning every 2-3 hours and addressing underlying conditions like diabetes or peripheral vascular disease are essential for healing. This conservative approach is recommended because premature debridement of stable eschar on the heel can expose deeper tissues and potentially lead to complications in this vulnerable area with poor blood supply.
Some key considerations in managing pressure injuries include:
- Offloading pressure to prevent further injury
- Maintaining a clean and dry environment
- Monitoring for signs of infection
- Providing adequate nutrition and hydration
- Regular repositioning to prevent further pressure injuries
- Addressing underlying conditions that may impact healing
It's also important to note that the use of specialized devices such as heel suspension devices, pillows, or specialized boots can help in offloading pressure and promoting healing 1. However, the most recent and highest quality study on this topic should always be consulted to ensure the best possible outcome for the patient. In this case, the study from 2024 provides the most up-to-date guidance on offloading foot ulcers in persons with diabetes 1.
In terms of specific interventions, the use of custom-made insoles, extra-depth footwear, and forefoot offloading shoes may be beneficial in relieving pressure and promoting healing 1. However, the choice of offloading modality should be based on the wound's location, the presence of any associated conditions, and the physical characteristics of the patient.
Ultimately, the goal of management is to promote healing, prevent further complications, and improve the patient's quality of life. By prioritizing offloading, wound care, and addressing underlying conditions, healthcare providers can help patients with black, intact pressure injuries on the heel achieve the best possible outcomes.
From the Research
Management of Pressure Injury in the Heel
- The management of a pressure injury in the heel that is black but not open involves preventing further pressure, friction, and shear forces on the affected area 2, 3.
- Elevation of the heel is indicated to reduce pressure and prevent shear and friction caused by movement 4.
- The use of prophylactic multilayer foam dressings applied to the heels, in conjunction with an evidence-based pressure injury prevention program, is recommended for prevention of pressure injuries on the heel 5.
- Heel protection devices can be used to relieve tissue interface pressure and protect the heel from shear and friction 4.
- Considerations for selecting an optimal heel protection device include its ability to elevate the heel, wick away moisture, and remain in place despite patient movement 4.
Risk Factors and Prevention
- The heel is a common site for pressure ulcer development, particularly in people who are supine or semi-recumbent due to immobility 2, 3.
- Risk factors for heel pressure ulceration include immobility, skin status, presence of previous pressure ulcers, and suboptimal tissue perfusion 3.
- Nurses play a crucial role in assessing the risk and preventing the development of heel pressure ulcers through techniques and devices such as heel elevation and protection devices 2, 3.