NURS9124: Problem Solving Case Analysis - Preventing Heel Ulcers

This case study addresses the problem of heel ulcers, particularly in high dependency units, by applying a five-step problem-solving process: identification, analysis, decision criteria, solution development, and optimal solution selection. It highlights the prevalence of heel ulcers, associated risk factors such as immobility, diabetes, malnutrition, and old age, and emphasizes prevention over treatment. The study proposes several solutions, including early ambulation, frequent position changes, calf elevation, leg elevation devices, and moisturizers. The optimal solution is identified as health education on risk factors and the implementation of strict institutional policies with regular evaluations. The case study draws from various research articles to support its analysis and recommendations, aiming to reduce the incidence and complications of heel ulcers in healthcare settings. This document is available on Desklib, a platform that provides various study tools for students.

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Running Head: PROBLEM SOLVING PROCESS
Heel ulcer prevention before and during hospital stay in high dependency areas
Author’s name:
Submission date:

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PROBLEM SOLVING PROCESS
Contents
Introduction.................................................................................................................................................2
Identification of the problem.......................................................................................................................2
Heel ulcer................................................................................................................................................2
Analyzing the problem.................................................................................................................................3
Risk factors associated with heel ulcer formation...................................................................................3
Identifying decision criteria.........................................................................................................................4
Developing solutions...................................................................................................................................5
Early ambulation for the clients...............................................................................................................5
Change of position every two hours........................................................................................................5
Elevating the patients calf on a pillow.....................................................................................................5
Use of devices that elevate the legs........................................................................................................5
Use of moisturizer...................................................................................................................................6
Choosing the optimal solution.....................................................................................................................6
Bibliography................................................................................................................................................7

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Introduction
Using the five step problem solving process of ; identification of the problem,
analyzing the problem, identifying the decision criteria, developing solution, and choosing the
optimal option (Sekaran 2016). I will analyze the occurrence and prevention of the heel ulcer in
the high dependency areas like the intensive care unit (Van Aken 2018).
Identification of the problem
Heel ulcer
Heel ulcer mainly occurs as a result of pressure and immobility of the leg especially
in patients who are bedridden for a long time and cannot ambulate especially those in the high
dependency areas such as the intensive care unit and high dependency unit. Immobility leads to
reduced blood flow, which in turn makes the skin of the heel weak and prone to tears even with
the slightest form of friction (Green 2017). Pressure also makes the prone to tenderness; pressure
is worsened by the reduced subcutaneous fat in the heel. If not treated heel ulcers can result in
osteomyelitis and limb amputation.
Preventing heel ulcer formation is the best strategy that can be instituted for patients
who are bed ridden for a long time, however if they develop treating them early will benefit the
patient from unnecessary medical expenses and complications such as septicemia, osteomyelitis
and limb amputation.

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Analyzing the problem
Heel ulcer is major problem with the prevalence rate of 25% across multiple
health care set-ups. Heel ulcers are the most common form of pressure ulcers in any hospital
setting. In every 3 pressure ulcers there is 1 heel ulcer (Baath 2016).
Risk factors associated with heel ulcer formation
The following factors will precipitate the formation of heel ulcers and they are;
abnomalities of circulation, comorbidity, dehydration, diabetes, major surgery, sensory
deficiency, advancing age, obesity, friction and shear forces, malnutrition, low albumin levels,
immobility and hip fractures (Delmore 2015).
Preventing a heel ulcer is better than curing one. Most patients who are bed-ridden
are at a higher chance of developing heel ulcer; the risk is increased by the anatomy of the heel,
which is minimal subcutaneous fat, a bony prominence and reduced blood supply to the heel.
The anatomy of the heel makes it easier for the heel to develop ulcers especially due to the
pressure applied on the heel when one is in supine position. Heel ulcers are especially worsened
by diabetes, old age, immobility and malnutrition.
Diabetes makes it almost impossible for any ulcer to heel due to the alteration in the
blood sugar and reduced sensation because of diabetes neuropathy; therefore a bed-ridden
diabetic person can develop a heel ulcer and the ulcer progresses to the second or third stage
without the person having any sensation of pain especially if they have nobody to check on them
regularly (Örneholm 2017).
Malnutrition impairs the skin integrity thus making it susceptible to tears especially
when there is friction. The skin is weak due to lack of the necessary nutrients it needs to maintain

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its patency and this is as a result of malnutrition (Gefen 2017). Old age can also result to
impaired skin integrity because of reduced uptake of nutrients from the gastro-intestinal tract as a
result of reduced gastric motility (Mishu 2015, july).
Immobility is a high risk factor that can result to formation of heel ulcers
especially in those who are bed-ridden in high dependency areas (Truong 2016). Most of the
clients in intensive care unit and high dependency unit sleep in the supine position, in this
position, body weight is not well distributed, with so much weight deposited on the heels. This
increases the pressure on the heels and due to their inadequate subcutaneous tissue, the heel are
prone to tears and erythema formation as a result of friction.
Identifying decision criteria
For a nurse to provide the best form of care, which ensures that all clients in the
intensive care unit and high dependency unit do not develop ulcers, they must come up with a
strategic plan to filter those at risk and those who are at no risk of developing ulcer. The nurse
must filter those who have multiple comorbidities which makes them highly susceptible to heel
ulcers, such us impaired neuron sensation. These clients should be given the first priority.
Another priority group is those in the intensive care unit and unconscious, this group of clients
requires meticulous care because they cannot do anything on their own, compared to those in the
high dependency unit with some mobility.
Classifying the clients in a systematic way enables the care provider to accord care
according to the needs of their clients, because not all clients require the same kind of care.

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PROBLEM SOLVING PROCESS
Developing solutions
There are many strategies associated with heel ulcer prevention, these strategies
include; early ambulation for the clients, change of position every two hours, elevating the
patients calf on a pillow, use of moisturizer to moisten the heels to reduce friction and tearing,
and use of devices that elevate the leg (Black 2015).
Early ambulation for the clients
In high dependency unit who are not unconscious but need the help of machines to
perform some physiologic functions or those who are under strict surveillance because of the
sensitivity of their condition, for instance someone who has just had a sickle cell crisis (Preston
2017).
Change of position every two hours
This applies to those who are totally unconscious, the nurse should change their
position frequently to enable good peripheral perfusion and relieve pressure on the heels.
Elevating the patients calf on a pillow
This can be done for both the unconscious and semi-conscious patients because it will
help relieve pressure on the heels by suspending them.
Use of devices that elevate the legs
There are devices that are used to elevate the leg, the nurse should use well-fitting leg
elevators and change them on every 8 hour shift, paying attention to any signs of redness.

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Use of moisturizer
This helps in adding moisture to the skin of the heel, which will prevent cracking
and tearing as a result of friction especially when moving the heels in different positions
(Lechner 2017).
Choosing the optimal solution
The optimal solution in preventing heel ulcers is health education on the risk
factors. Also the institution should have a strict written policy on the preventive strategies for
heel ulcers and strict evaluation of these strategies to ensure they are being followed as required.

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Bibliography
Baath, C,EM,GLAAAM 2016, 'Prevention of heel pressure ulcers among older patients-from ambulance
care to hospital discharge: A multi-centre randomized controlled trial.', APPLIED NURSING RESEARCH,
vol 30, pp. 170-175.
Black, J,CM,DC,BCT,AP,SNACE, 2015, 'Dressings as an adjunct to pressure ulcer prevention: consensus
panel recommendations', International wound journal, vol 12, no. 4, pp. 484-488.
Delmore, B,LS,SB,RLAAEA, 2015, 'Risk factors associated with heel pressure ulcers in hospitalized
patients.', Journal of Wound Ostomy & Continence Nursing, , vol 3, no. 42, pp. 24@-@$8.
Gefen, A 2017, 'Why is the heel particularly vulnerable to pressure ulcers?', British Journal of Nursing, ,
vol 26, no. Sup 20, pp. S62-S74.
Green, L 2017, Development of an Automatic Heel Ulcer Prevention Mattress.
Lechner, A,LN,NK,B-PUAKJ, 2017, ' Dry skin and pressure ulcer risk: A multi-center cross-sectional
prevalence study in German hospitals and nursing homes.', International journal of nursing studies, vol
73, pp. 63-69.
Mishu, MCASJW, 2015, july, ' Modelling of pressure ulcer (PU) risk prediction system.', In Science and
Information Conference , vol (SAI), 2015, no. IEEE, pp. (pp. 650-656).
Örneholm, H,AJ,LJAEM, 2017, 'Heel ulcers do heal in patients with diabetes. ', International wound
journal, vol 4, no. 14, pp. 629-635.
Preston, A,RA,SR,SRAZD, 2017, ' Deep tissue pressure injury: a clinical review. ', AJN The American
Journal of Nursing, , vol 117, no. 5, pp. 50-57.
Sekaran, UABR, 2016, Research methods for business: A skill building approach., John Wiley & Sons.
Truong, B,GE,PMALX, 2016, ' Pressure Ulcer Prevention in the Hospital Setting Using Silicone Foam
Dressings.', Cureus, vol 8, no. 8.
Van Aken, JEABH, 2018, Problem solving in organizations., Cambridge University Press.

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