Regarding Heel Ulcers Without Eschar

[AtheistRN, ADN, RN]

Hi all,

I'm an RN working in a skilled facility and have a question for the experts about heel ulcers. My understanding is that when stable eschar is present, this is usually "left alone". What about when heels have 2-3 degree ulcers with slough, drainage, and odor? I suggested sharp debridement by MD, but other nurses have said that heels don't fare well, being distal, etc, and should be "left alone." This does not make sense to me, especially if the pt is not diabetic.

Your input is appreciated.

[mommy.19, MSN, RN, APRN]

The main concern is circulatory compromise to the limb. If the eschar is intact without edges lifting, is firm to the touch without exudate or surrounding erythema, it is considered 'stable', and is often kept dry and padded, and monitored. If it is malodorous, the edges lift away from the wound base, or the eschar becomes mushy/boggy and develops exudate, it is 'unstable' and will likely need debridement of grossly necrotic tissue in order to reduce the bioburden and decrease the chances of systemic infection. Most providers do not wish to perform debridements in potentially ischemic limbs due to the nature of ischemia, knowing there is not a great chance for wound healing. However, the patient should be assessed for the potential for vascular intervention if possible. It is not standard of care to leave grossly infected detritus on a wound simply because 'they don't have good circulation.' The patient and family wishes should be kept in mind, along with other comorbid conditions the patient suffers from to assess potential for wound healing.

[AtheistRN, ADN, RN]

Thank you for your response. The issue here is no eschar whatsoever, just large open wounds with slough.

[mommy.19, MSN, RN, APRN]

In that case, I would assume it is the latter part of my post, which refers to fear regarding poor circulation. I would query the provider if they desire circulatory studies before proceeding with debridement. The best thing is for the patient to see a vascular specialist so erroneous studies are not ordered. Hope this helps.

[RNtraveler2014]

depending on how much the wound is draining the dressing would need to be changed possibly up to 4x a day and as needed for drainage. elevation; offloading. no debridement unless necessary, until the wound would have less drainage. if there is drainage i would ensure to protect the edges of the wound to prevent further breakdown d/t stagnant drainage which could lead to further issues (IE: larger sore; higher r/o infection ect...). TOTALLY agree with mommy.19, the MD would need to do testing on BLE to test circulation and see what else is going on so further incidences can be prevented (hopefully), always depending on how responsible the pt is. lol

[mommy.19, MSN, RN, APRN]

The suggestion of changing the dressing up to 4 times daily is not supported by literature or current knowledge of moist wound healing principles. I would advise against this.

[Lee J A]

You should be aware of a pts vascular status before a sharp debridement. If your facility doesn't do ABI's, you should send them out for arterial studies. If that isn't a option and you aren't able to send the pt to a wound clinic, I would suggest using Santyl on the wound.