In his practice, Dr. Wendelken most often finds pressure ulcers on the heel, typically the retrocalcaneal surface and the lateral heel. He also encounters numerous pressure ulcers on the ankle over the malleolus as well as pressure ulcers along the lateral aspect of the foot (base of the fifth metatarsal at the styloid process). In his clinic, Dr. Suzuki has seen quite a few “ankle” pressure ulcers over the lateral malleolus or even the medial malleolus as some of his patients sleep on their sides. This may turn the ulcer into a chronic ulceration at the tip of the malleolus, according to Dr. Suzuki. the patient has limited mobility (i.e., the patient cannot independently make changes in body position significant enough to alleviate pressure and at least one of the conditions A-D below); or

A stakeholder wanted to draw attention to limitations of moist wound care. However the current surveillance review identified 2 RCTs showing benefit of moist dressings, which agrees with the guideline recommendation to consider using a dressing that promotes a warm, moist wound healing environment. Dr. Sage evaluates the wound for signs of infection and evaluates the foot for signs of ischemia. If infection is present, he says debridement and/or antibiotics may be necessary, but he does not debride stable, non-infected blisters or eschars. When a new patient presents with what appears to be a pressure ulcer on the lower extremity, Dr. Wendelken proceeds with a vascular assessment that includes an ankle/brachial index, a neuropathy assessment that utilizes the Semmes Weinstein test, and an assessment of mobility and range of motion. NICE guideline CG179 recommendations 1.4.3 and 1.5.3 refer to the International NPUAP‑EPUAP [2009] Pressure Ulcer Classification System. This has had 2 revisions since 2009, therefore the reference to a specific year will be deleted. Integrated Anti-Rotation Wedge helps prevent lateral rotation, reducing risk of peroneal nerve damage

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A cross-referral to the NICE guideline on nutrition support for adults will be made from recommendation 1.4.5.

Another study published in JWOCN demonstrated a 100% prevention of both heel pressure ulcers and plantar flexion contracture over a seven month period when using the heel protector device. 3 Forty patients will be randomised, 20 to receive Prevalon boots and 20 to receive the standard pressure ulcer prevention method used by the ward they are on, to be used whilst in bed. Patients will be assessed daily for 10 days and at each assessment their heels will be photographed using a high resolution digital camera. A blinded assessor will assess all of the photographs to determine whether pressure damage has occurred at the heels. Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles, and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo. A cross-referral to the NICE guideline on sepsis: recognition, diagnosis and early management will be made from recommendation 1.4.18.A stakeholder queried if frail older people should be a separate category in the guideline. No evidence was found about this issue by the current surveillance review. The Waterlow score (1 of 3 tools the guideline recommends considering for assessing ulcer risk) includes items for age, and skin type (for example tissue paper - thin/fragile). No impact on the guideline is currently expected. A study published in JWOCN found the use of Prevalon and a heel ulcer prevention protocol led to a 95% decrease in heel pressure ulcers. 2 Oftentimes, Dr. Suzuki sees pressure ulcers starting with a period of immobility, such as when patients are acutely ill and hospitalized for a period of time. Sometimes, Dr. Suzuki notes pressure ulcers may develop slowly at home if patients have inappropriately hard bedding surfaces, poor dental condition (which is extremely common in older patients) and gradual malnutrition, which he notes may cause a slow deterioration of their skin. Individuals in bed who are completely immobile should have a care plan that includes the use of devices that totally relieve pressure on the heels, most commonly by raising the heels off the bed.” 2