Nursing practice often involves undertaking procedures about which there is debate or uncertainty. In Practice Question we ask experts to determine how nurses should approach these situations
Q. Should we be using water filled gloves under the heel to prevent pressure ulcers?
A. The short answer is no - this practice is outdated and has no evidence to support it. To understand why the use of water filled gloves to prevent pressure damage constitutes poor and possibly negligent practice, it is necessary to know why heels are vulnerable to pressure damage and why the use of water filled gloves provokes concern.
Pressure ulcers are localised areas of tissue damage, usually over a bony prominence, which result from pressure or pressure in combination with shear (European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel, 2009). After the sacrum, the heel is the most common site of pressure ulcers (Whittington and Briones, 2004; Meehan, 1994).
The heel is vulnerable for many reasons; perhaps the most significant is the relatively thin layer of subcutaneous tissue that covers the calcaneus (heel bone), leaving small blood vessels more exposed to damaging pressure and shearing forces (particularly where patients are confined to bed).
Risk is raised by comorbidities such as diabetes and peripheral vascular disease compromising the distal vascular supply (Junkin and Gray, 2009).
Latex surgical gloves have been in use for around 100 years, becoming commonplace as a disposable item in the 1980s. By the 1990s these gloves, filled with water, tied at the wrist and placed under the heel, appeared to be in common use as pressure ulcer prevention aids (Williams, 1993) although their clinical effectiveness had never been established.
The effectiveness of these as pressure ulcer prevention aids depends on the pressure at which small vessel occlusion occurs and the pressure exerted on the small vessels by the glove itself. The point of vessel occlusion varies between individuals, according to factors such as age, health and weight. An early benchmark was provided by Landis, who found a mean arteriole pressure of 32mmHg in his study of fingernail capillary pressures, with the range starting as low as 21mmHg (Landis, 1930). His findings were influenced by the youth and health of the volunteers, who could presumably tolerate higher pressures than the typical patient at risk of pressure damage.
The pressure exerted by water filled gloves on the heel depends on the patient’s weight, the amount of water and the size of the glove.
A small study (Lockyer-Stevens, 1993) used non sterile disposable latex gloves of different sizes filled with varying volumes of water. Heel pressures were measured on an ordinary mattress surface with and without the gloves. Although the gloves exerted lower pressures than the mattress surface, none exerted a pressure below the “Landis mean” of 32mmHg. In addition, the volunteers remained still; in reality patients often move, which could affect the glove’s positioning and the pressures exerted. Lockyer-Stevens also reported that a standard NHS mattress was used. Had the heel pressures been compared using a modern pressure reducing surface, the findings might have been considerably different.
A similar study by Williams (1993) used gloves filled with 260ml of water, an amount based on an examination of six gloves. In this study of 40 people, again comparing the pressure exerted by an ordinary mattress with that exerted by a water filled glove, the heel pressures were on average 12.5% higher with the gloves, leading the author to conclude that the use of water filled gloves was ineffective and ritualistic. An additional concern was that tape or bandages used to position the glove could damage tissue.
The variety and effectiveness of pressure care aids have improved significantly and guidance has been published on pressure ulcer prevention and care (EPUAP/NPUAP, 2009; NICE, 2005). The most recent of these states that the use of water filled gloves under heels should be avoided (EPUAP and NPUAP, 2009).
Julie Vuolo, MA, BSc, DipHE, RGN, is senior lecturer, University of Hertfordshire
European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel (2009) Prevention and Treatment of Pressure Ulcers:Quick Reference Guide. Washington, DC: National Pressure Ulcer Advisory Panel.
Landis EM (1930) Studies of capillary blood flow in human skin. Heart; 15: 209-278.
Lockyer-Stevens N (1993) The use of water-filled gloves to prevent the formation of decubitus ulcers on the heels. Nursing Times; 2: 5, 282-285.
Junkin J, Gray M (2009) Are pressure redistribution surfaces or heel protection devices effective for preventing heel pressure ulcers? Journal of Wound, Ostomy and Continence Nursing; 36: 6, 602-608
Meehan M (1994) National pressure ulcer prevalence survey. Advances in Wound Care; 7: 3, 27-30, 34, 36-8.
NICE (2005) The Management of Pressure Ulcers in Primary and Secondary Care. London: NICE.
Williams C(1993) Using water-filled gloves for pressure relief on heels. Nursing Times; 2: 6, 345-347.
Whittington K, Briones R (2004) National prevalence and incidence study: 6-year sequential acute care data. Advances in Skin and Wound Care; 17: 9, 490-494.