How to manage a patient with Alzheimer's disease and a deep tissue injury to the heel when selective debridement is complicated by poor access due to difficult positioning?

Management of Deep Tissue Injury to the Heel in a Patient with Alzheimer's Disease

For a patient with Alzheimer's disease and deep tissue injury to the heel where selective debridement was complicated by poor positioning, it is recommended to document the challenges encountered and implement appropriate follow-up care to prevent wound deterioration and possible amputation.

Documentation for Progress Note

Assessment:

• Patient with Alzheimer's disease presented with deep tissue injury to heel requiring selective debridement 1
• Procedure was initiated to remove calloused tissue but could not be completed due to: 1
  • Poor access to the heel area
  • Patient positioned in recliner
  • Difficulty with optimal positioning due to patient's Alzheimer's disease

Plan:

• Schedule follow-up appointment within one week 1
• Implement appropriate off-loading strategies to relieve pressure on the affected heel 1
• Consider interdisciplinary care team consultation for complex wound management in a patient with cognitive impairment 1
• Document wound characteristics including size, depth, and presence of infection indicators for comparison at next visit 1

Comprehensive Management Approach

Immediate Interventions

• Classify the wound as a "stable" or "unstable" deep tissue injury to determine urgency of follow-up 1
• If signs of infection are present (erythema, warmth, purulent discharge), expedite follow-up within 24-48 hours 1
• Implement appropriate wound dressing based on wound characteristics 1:
  • Continuously moistened saline gauze for dry wounds
  • Hydrogels for dry/necrotic wounds
  • Alginates for exudative wounds

Addressing Positioning Challenges

• For patients with Alzheimer's disease, consider:
  • Scheduling appointment when caregiver support is available 1
  • Using a treatment table rather than recliner for better access 1
  • Employing distraction techniques or mild sedation if appropriate 1
  • Requesting assistance from additional staff for proper positioning 1

Off-loading Strategies

• Implement pressure relief measures such as pillows or rolled sheets under the calf to elevate the heel 2
• Consider specialized heel off-loading devices or cushioning materials 1
• Ensure proper footwear when ambulatory to prevent further pressure damage 1

Follow-up Care Plan

• Schedule follow-up within one week to complete debridement 1
• Consider referral to specialized diabetic foot service or wound care team if:
  • Wound shows signs of deterioration 1
  • Infection develops 1
  • Complete debridement cannot be achieved in office setting 1

Special Considerations for Patients with Alzheimer's Disease

• Patients with cognitive impairment require additional support for wound care compliance 1
• Educate caregivers about:
  • Daily inspection of the heel 1
  • Signs of infection requiring immediate attention 1
  • Proper positioning techniques to relieve pressure 2
  • Importance of maintaining follow-up appointments 1

Potential Complications to Monitor

• Deep tissue injuries to the heel have high risk of progression to full-thickness wounds 3
• Patients with limited mobility and cognitive impairment are at increased risk for wound deterioration 2
• Heel ulcers that become infected or necrotic may require surgical intervention if not managed promptly 1
• Without proper off-loading, even stable wounds can deteriorate rapidly 1

Documentation of Incomplete Procedure

"Patient with Alzheimer's disease presented with deep tissue injury to right/left heel. Selective debridement was initiated to remove calloused tissue; however, procedure could not be completed due to poor access to the heel with patient positioned in recliner. Patient's cognitive status limited ability to maintain optimal positioning for complete debridement. Partial debridement of accessible callus was performed. Wound appears stable without signs of active infection. Applied [specific dressing] and instructed caregiver on proper off-loading techniques. Will follow up in one week to complete debridement with plan for improved positioning including [specific positioning strategy]. Caregiver educated on signs of infection requiring earlier follow-up."