Let the NPIAP Guideline guide you
The authors of the NPIAP Guideline explain: “Strength of recommendations indicate the extent to which one can be confident that adherence to a recommendation will do more good than harm and are intended to assist health professionals to prioritize interventions.”1
When the NPIAP Guideline authors deemed an area of practice important to address, but didn’t find enough evidence to support a recommendation, they created “Good Practice Statements.” James notes, “Facilities often use good practice statements to help write policies and procedures for skin health, incorporating them so that nurses can provide patients with the most current and up-to-date processes.”
Guideline strength levels1
Here is how the NPIAP breaks down each strength and recommendation level.
It’s up to you, your team and your organization to decide which recommendations and good practice statements fit into your policies and protocols. Incorporating them into your everyday practice can help you feel confident about doing the right thing for your patients.
One section of the NPIAP Clinical Practice Guideline focuses on the prevention and treatment of pressure injuries on the heels (pages 145 to 154). Why a specific area dedicated to heels? Because studies show that as many as 38.5 percent of stage 4 pressure injuries occur at the heels.1
The Guideline authors explain, “Because the heel is covered with a small volume of subcutaneous tissue, mechanical loads are transmitted directly angular to the bone.” 1 The Guideline recommendations are meant to help staff standardize heel skin assessments, positioning and protection of heels.
Review the NPIAP Guideline’s main points about heel protection to help reduce your patients’ risk of pressure injuries:
A heel assessment should include 4 things: 1
- Physical assessment of the heel
- Patient’s past clinical history
- Previous heel pressure injuries
- Current physical and medical status
Assessment considerations: 1
- If a patient has peripheral arterial disease, it may increase their risk of heel pressure injuries.
- Check skin on heels regularly, even if a prophylactic dressing is being used.
- Evaluate blood supply to the heel by checking
- Skin temperature
- Peripheral pulses
- Skin color
- Skin quality and appearance
- Patient’s sensation to touch
Be sure to offload the heel completely to distribute the weight of the leg along the calf without placing too much pressure on the Achilles tendon and the popliteal vein, a major lower body blood vessel.1
With individuals who already have a stage 3 or greater heel pressure injury, the same applies. However, it is not recommended to use pillows or foam cushions, only specifically designed heel suspension devices.
Strength of evidence: B1
Strength of recommendation: ⇡ ⇡
- Ensure heels are free from the surface of the bed.
- Knee should be flexed about 5 to 10 degrees.
- Distribute pressure evenly.
- Use a positioning device if necessary.
- Remove the heel suspension device regularly to assess skin integrity and perfusion status.
Choose a heel suspension device that takes into account the following:
- Individual’s clinical condition and leg mobility
- Skin integrity and swelling
- Anatomical appearance and alignment of the hip, foot and lower leg
- Individual care plan
- Patient’s comfort in the device
- Manufacturer’s guidelines
NPIAP Good Practice Statement 6.3: The NPIAP also includes a good practice statement that also recommends elevation of the heel using a device for heel suspension for patients with a stage 3 or greater heel pressure injury.
Strength of evidence: B1
Strength of recommendation: ⇡
Prophylactic dressing considerations:
Keep these things in mind when selecting a prophylactic dressing:
- Dressing size and design
- Ability to manage microclimate
- Ease of application and removal
- Ability for the dressing to stay on
- Ability to regularly assess the skin under the dressing
- Patient preference, comfort and any allergies
- Friction between the skin and the dressing
- Cost and accessibility
When it comes to pressure injury prevention and treatment, you don’t have to choose between evidence-based protocols and best practice: Evidence-based is best practice. The NPIAP’s Clinical Practice Guideline offers caregivers important recommendations and good practice statements to help prevent and treat pressure injuries, all based on research. Heel protection is an important section in the Guideline because of the high prevalence of pressure injuries at the heel. With proper assessments, elevation and dressings, you can help reduce the risk of pressure injuries for your patients.