A 78-year-old woman is brought to the office for evaluation of a right heel wound. She had an ischemic stroke a year ago with residual right hemiplegia and has lived in a nursing home facility since. The patient also has oropharyngeal dysphagia and is fed through a gastrostomy tube. For the past several weeks, she has had a gradually enlarging right heel ulcer She has no pain sensation in the right leg and has had no fever or foul-smelling drainage. Her other medical problems include hypertension, type 2 diabetes mellitus, and coronary artery disease.
Right heel examination shows a 2-cm ulcer with thick, firm eschar. There is no crepitus or surrounding redness. The lower-extremity pulses are weak.
Which of the following is the best next step in management of this patient?

Question

A 78-year-old woman is brought to the office for evaluation of a right heel wound.  She had an ischemic stroke a year ago with residual right hemiplegia and has lived in a nursing home facility since.  The patient also has oropharyngeal dysphagia and is fed through a gastrostomy tube.  For the past several weeks, she has had a gradually enlarging right heel ulcer   She has no pain sensation in the right leg and has had no fever or foul-smelling drainage.  Her other medical problems include hypertension, type 2 diabetes mellitus, and coronary artery disease.
Right heel examination shows a 2-cm ulcer with thick, firm eschar.  There is no crepitus or surrounding redness.  The lower-extremity pulses are weak.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9790_a78d_853d_a1ff2f6dbd45_MD0002_00 This patient has an unstageable heel pressure ulcer, defined as full-thickness skin loss covered by eschar that obscures the ulcer base. Unstageable ulcers are usually stage III or IV, although the true depth cannot be determined unless eschar is removed to expose the base of the wound. Heel pressure ulcers are managed differently from those at other sites due to limited thickness of subcutaneous tissue and proximity of the underlying bone. Removing tissue around the heel can increase the risk of osteomyelitis. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as a natural protective cover and should not be removed. Instead, patients are usually treated initially with conservative measures, including pressure redistribution, pain control, and optimized nutrition. Proper positioning to redistribute the pressure is the most important intervention to increase tissue perfusion, improve healing, and prevent future ulcers. Some patients may need support surfaces or devices (eg, orthotic device, foam boot) for adequate pressure relief. Iodine paint to keep the area dry or enzymatic debriding agents may also be used. Measures to control pain include oral medications and topical anesthetics (eg, lidocaine). Because pressure ulcers cause a chronic catabolic state, adequate caloric intake is also required for proper wound healing. (Choice A) There is insufficient evidence that hyperbaric oxygen therapy provides benefit in treating pressure ulcers. (Choice B) All pressure ulcers are colonized with bacteria; intravenous antibiotics are typically recommended only for clinically evident infections (eg, fever, erythema, purulent drainage) or deep-tissue involvement. (Choice D) Surgical debridement is usually recommended for pressure ulcers with clinically evident infection, extensive tissue necrosis, or failure to improve with conservative therapy. However, it is otherwise not recommended for heel pressure ulcers as the close proximity of the bone can increase the risk of osteomyelitis. (Choice E) Wound swab culture usually reflects skin colonization and is not useful for determining the true microbiology of an infection. Needle aspiration or deep-tissue biopsy is more effective if needed. Educational objective: Heel pressure ulcers are usually managed conservatively as removing tissue around the heel can increase the risk of osteomyelitis. Proper positioning to redistribute the pressure is the most important intervention to improve healing. __________ References: Practice recommendations for preventing heel pressure ulcers. (http://www.ncbi.nlm.nih.gov/pubmed/18927483) Preventing and managing heel pressure ulceration: an overview. (http://www.ncbi.nlm.nih.gov/pubmed/22875028)

A 78-Year-Old Woman Is Brought to the Office for Evaluation