Nasty heel

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    I have recently taken on a patient for case management who developed a deep ulcer on his heel (brain injury, tends to grind that heel into the bed) after about a month in a snf. The documentation says it had a "hard dry callus" with a small crack it it, and they didn't do anything about it, kept him in regular shoes when up, no heel protection in bed. In a week was unstageable due to necrosis, got sharp debridement, blah blah blah. It's a nasty looking wound. There is no WOCN in the facility or on call, though they do have a physician that looks at things prn.

    My question is, what was this "callus" they thought they saw, and should they have recognized that better heel flotation/soft booties/something in the nursing realm might have prevented this wound from progressing this far in a week? Or was it reasonable that it was a surprise to them?
  2. 9 Comments so far...

  3. 0
    Hello,

    So, you are now managing the case (provider continuity), right?

    Did you ask the previous staff what they thought this "callous" was?

    You ask:

    should they have recognized

    something in the nursing realm might have prevented

    was it reasonable that it was a surprise
    I guess my question is now that the case has come to you, are you educating the staff/facility on exactly what this was complete with allowing them questions/answers about what was developing as well as educating for future similar scenarios regarding wound care?
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    In this case I was just hired by family members as a case manager to help with issues around a hospitalization and (now) SNF care. There was no skin damage when the patient entered the SNF about 6 weeks ago. I not a WOCN and am not up on the current state of dressings and treatment (other than unloading and debridement) for pressure ulcers, and there is no WOCN on their staff-- wound care is done by a staff member who is their facility resource, but she appears to have no power to order changes, and doesn't seem to know much about anything other than skin barrier spray and those big bandaids you put on your kid's scraped knee. She described this "callus" as a hard dry area with no discoloration, and when she saw it a week later it was red and purple with black eschar. Then she had a physician look at it and that's when the debridement was done. A week after that was when I saw the heel for the first time, with bandaid and fluffy boot, but the boot comes off when the shoes go on for PT. (Since the patient can't walk I don't see the point of the shoes.)

    She means well but it's clear that this went really rotten in a week because nobody was watching it. I would like some information on what ought to be happening from here (other than unloading), such as dressings, dressing changes (how often), and such so I can monitor the situation. So I came here to ask a real WOCN for some ideas.
    Last edit by GrnTea on Dec 26, '12
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    In this case I was just hired by family members as a case manager to help with issues around a hospitalization and (now) SNF care.
    I understand.

    There are WOCN nurses who can help you with some of the questions you have about monitoring present situation.

    "Helping with issues around a hospitalization".... " but it's clear that this went really rotten in a week because nobody was watching it." ..... we just have to ensure that your inquiry is for present/future care to maintain/improve the situation for your patient and not gathering information to try and (medically/legally) answer what could have happened before he became your client.
    Last edit by sirI on Dec 26, '12
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    I am not there to ding anybody, I just want him to get better care and it will be easier to do that if I know more about what I'm seeing. So if you need/want to edit our conversation before you post it, feel free.
    sirI likes this.
  7. 0
    Quote from GrnTea
    a week later it was red and purple with black eschar. Then she had a physician look at it and that's when the debridement was done.
    red and purple sounds like deep tissue injury (DTI) that turned to black eschar. Who did the debridement? They should have recommended a treatment after the debridement.

    You said you saw the wound, right? What is the size? How's the wound bed? Any slough or drainage?
  8. 0
    If the wound is not draining, I would recommend an antimicrobial cream like Silvadene (make sure no allergy to this including sulfa) and write my order as follows: Right heel-Cleanse with NSS. Pat dry. Apply Silvadene cream. Cover with 4x4 and ABD. Wrap with Kerlix daily, PRN x 14 days. I would also recommend pillow under calves for heel elevation. I will ask the MD for a "no shoe order" on the affected foot. Follow up also if the patient has any arterial or venous issues.

    I will follow-up on this wound weekly to track the progress and see if I need to order a different treatment.

    FYI: I'm not WOCN and I have only been doing wound care for several months.
  9. 0
    Many thanks. I have forwarded this info to the clinical nurse on the floor, and we'll see what happens. Meanwhile, any other WOCNs around, I'd love your opinions.
  10. 0
    Tissue injuries in compromised patients can happen in a matter of hours. I am curious if the wound is on the plantar aspect of the foot or the posterior aspect (or if it involves both). I manage an outpatient clinic, and unfortunately many of our new admits are currently in PT with FULL weight bearing exercises, and also have ischemic heel ulcers. We spend a lot of time on the phone with the practitioners that have ordered this PT explaining to them why it is complicating the wound healing process.

    My first step would be to recommend a blood flow assessment of his lower extremities, which is generally done before any sort of sharps debridement is attempted. If the arterial status is poor, then vascular intervention may be a possibility. If the blood flow is poor and intervention is not possible, then trying to keep the wound dry, covered, and free of contamination is generally the best plan. If the blood flow is sufficient, the next step would be a wound management plan with potential sharps debridement with moist wound dressings, and possibly a dietary consult (this is all difficult to determine since I have never seen this patient, but hopefully you get the idea). Also, as mentioned above, I would consider putting PT on hold.
  11. 0
    Younger man with a brain injury, good vascular supply, eats everything they put in his mouth. I have asked the MD about checking prealbumin, testosterone, and serum vitamins for wound healing. Wound is on posterior aspect but slightly creeping around to plantar, consistent with his neurogenic forcible extension of the leg pushing the heel down into the bed. They have been reconsidering his PT for walking as his rehab potential is very poor. I have forwarded your information, and thank you very much for your ideas.


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