The "Boggy" Heel

Linda Lankenau MSN, RN, CWON

I’m trying to determine just what that is, and more importantly its significance to the development of a heel pressure ulcer.

I think I first really became aware of the word in relation to pressure ulcers when the NPUAP (National Pressure Ulcer Advisory Panel) added deep tissue injury to the staging system in 2007. In the medical dictionary, “boggy” refers to abnormal texture of tissues characterized by sponginess, usually because of high fluid content. In the NPUAP definition of suspected DTI it is used to help describe tissue that is painful, firm, mushy, warmer or cooler to the touch compared to adjacent tissue; or when assessing heel skin, compared to the other heel.

At a recent lunch and learn with a team of skin care nurse advocates in New Jersey the question came up with regard to how you both assess and treat “the boggy heel”. We wondered if it is consistently a precursor to a significant heel ulcer. Or is it an early sign of a heel ulcer that can be reversed with proper intervention? Is it normal anatomy for some patients? Does it occur more in older vs. younger patients because tissue tolerance to pressure and shear is lower in the older population? Is it more likely to happen in patients with lower extremity edema? Is it less likely to happen in patients who are ambulatory because of better venous return with ambulation? Clearly, lots of unanswered questions…

But that didn’t mean no action was to be taken. As a result of our conversation we decided the skin care team would remind all nurses and nursing technicians to make sure heel skin assessments would be done consistently, both on admission and through-out a patient’s length of stay in the facility.  The presence of risk factors including LE venous or arterial disease and/or edema, diabetes, immobility, and patient acuity would be key alerts for staff for all patients. Suspected heel DTI signs/symptoms and significance would be reviewed. When the “boggy heel” was thought to be present by the RN along with patient reports of pain and assessments of increased tissue warmth or coolness compared to the opposite heel, a heel protective device would be placed. If both heels appeared equally compromised, each would receive a heel protector. Assessments and treatment interventions would be documented in the electronic medical record.

The facility and its three affiliates will all be using the new EHOB WAFFLE® Custom Heel Elevator, or the Foot WAFFLE® which can accommodate larger or edematous legs. The nurses were very enthusiastic about having the soft and comfortable static air products for prevention and treatment of their patient’s heels.

Although we did not solve the problem of the significance of “the boggy heel”, all recognized the significance of how harmful a heel pressure ulcer can be and how inexpensively patients can be protected from so many of them.